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U.S. Department of Health and Human Services

Action Steps: Phase 1

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


Phase I: 0-24 hours post-detonation

Line number


Information Source

General Readiness Planning and Emergency Management


Response for nuclear detonation begins following reports by public safety that incident magnitude suggests nuclear detonation.



Assure immediate assessments for radiation by public safety personnel / first responders



Upon confirmation of radiation presence, coupled with catastrophic explosion, immediately activate EAS for areas potentially within dangerous fallout zone and blast zones and instruct persons to immediately take shelter inside the largest available building



Contact or deploy airborne assets (helicopters – law enforcement, media, others) for visual report on debris cloud drift



Contact National Weather Service for Doppler radar information on cloud drift/movement or work through IMAAC (Department of Energy) or DHS.



Issue further EAS activations as needed for the anticipated fallout zone. Contact other jurisdictions as needed



Notify state and request disaster declaration (state and Federal), request ‘no-fly’ zone over fallout locations and 2 miles in all directions from apparent epicenter aside from medical flights



Institute incident command, open jurisdictional EOC and initiate callbacks/notifications including obtaining state or Federal radiologic consultation (Radiation Assistance Program – RAP) and public health consultation

IS# 20


Begin to obtain situational awareness from public safety – impact, status of 911 and other communications systems and inform state EM of the magnitude of the situation and on the physical location. Developing and maintaining situational awareness will be a continued struggle over the next several days in the dynamic response environment and will require significant resource commitment.

IS #4


Assign a mapping/modeling unit and begin to assemble known data, readings, and wind/weather information to begin assembling data to predict response zones (SD, MD, LD and DF zones). Work with HHS for MedMap access.



Implement Continuity of Operations Plans as needed based on incident impact



Appoint PIO and initiate JPIC, issue initial messages to media and schedule press conference



Deploy additional field radiologic monitoring



Obtain situational awareness support from DHS and HHS. Radiation and plume modeling to guide response. Initial data will be supplemented by on-site measurements of where radioactivity is and is not. Begin to define evacuation guidance for dangerous fallout zone based on mapping



With public health, define shelter locations, Assembly Centers and possible Medical Care centers – assure logistical support for these locations and publicize these locations to community and responders



Determine key transportation routes identified by law enforcement and fire/EMS and need for debris clearance. Identify and deploy public/private assets to clear glass and vehicles supporting access to light and moderate damage zones.



Assure regional staging locations identified. Designate staging areas for both incoming and outgoing personnel and supplies.



Communicate with the public in a coordinated manner to minimize confusion. Coordinate with Federal information centers. Be prepared if “talking heads” provide contradictory opinions and monitor media outlets.



Through state, request:

  • SNS push-pack deployment and myeloid cytokines VMI deployment
  • HHS activation of National Disaster Medical System (NDMS) and other HHS assets (DMATs and burn teams). HHS to activate AABB TF for blood supports through Assistant Secretary for Health (ASH) activate RITN; Veterans Administration activated
  • FEMA EMS contract activation for initial 100 EMS units
  • FEMA Urban Search and Rescue Teams
  • State National Guard assets for transportation, debris removal, security, logistic support
  • Heavy lift equipment and debris clearing equipment, supplemental lighting and portable generators, fuel, etc.
  • Cellular on wheels and other communications support for areas damaged by EMP including amateur radio
  • EMAC requests as needed to meet EMS and logistic needs

IS #9
IS #11


Assure activation of reception site for Strategic National Stockpile (SNS) assets.



Anticipate logistical needs for inbound resources (road and air) and begin to plan for outbound evacuation of patients and evacuees


Emergency Medical Services


Recognize incident. Implement incident management and response plans, initiate callbacks and augment personnel.



Assess status of 911 system and implement call triage at PSAP and medical dispatch – recommend self-transport in all cases when possible



Create accountability system to determine which crews are unable to be contacted or are sheltering in dangerous fallout areas. May be unable to contact many crews within a few miles of blast initially due to cell tower damage.



Request regional EMS resources to staging location and request mutual aid to support briefing and assignment at that location



Establish position in EOC / HMCC to coordinate EMS response



Emphasize with crews coordination with fire department, definition of response zones, direction of walking wounded out of area, focus on hemorrhage control and herding.



Triage, treatment, transportation of acutely wounded- Triage based on usual trauma criteria including considerations of limitations on critical care and transportation in the early aftermath
Utilize the RTR system for designating sites. RTR-1, -2 and -3

IS #3


Based on evolving response and situational awareness, begin to assign crews to establishing areas of treatment (RTR1,2,3) and assign divisional supervisors to these sites under NIMS – every effort should be made to create unified divisional command with fire and law enforcement

IS #3


Determine access problems to affected LD and MD areas and pass needs/requests to EOC



Provide support / care at assembly centers / shelters / medical care sites including directing mutual aid resources to these locations



Identify depleted and needed resources and regional sources to back-fill, plus request re-supply from state / federal sources



EOC liaison should begin to work with EM and PH on plans for staffing evacuation hubs and assembly / medical care sites over subsequent days. Request regional assistance for staffing and resourcing these locations as needed.


Healthcare Facility Response


Recognize incident. Implement incident management and response plans, initiate callbacks and augment personnel.



Activate radiation response teams and deploy radiation assessment equipment



Assess facility for damage and impact on operations; Assess staffing and capacity. Implement surge capacity plans. Move pre-designated supplies to ED and other triage/treatment areas



Triage, treatment of victims of trauma / combined injury
Continually reassess survivors as scarce resource setting changes. Priority in scarce resource setting is on hemorrhage control and other rapid stabilizing measures. Complex surgeries and definitive management should NOT be undertaken at this time. Focus on moderately injured with single-system injuries amenable to rapid correction to prevent life/limb threat.

IS #14


Establish minor triage/treatment areas on site (lobbies, classrooms, garages) and off-site (nearby school, church, lobby of large building, etc)



Assess critical medical supplies. Contact suppliers, sharing partners and HMCC / EOC with needs and issues

IS #8


Assess current in-patient population to see who could be discharged and/or transferred to free up beds and resources for the expected influx of victims.



Liaison with EMS or contact HMCC to determine options for patient movement to other sites via bus, ambulance, air depending on situation and ability to access facility



Establish decontamination site and activate victim flow plans. Deploy ‘dry decon kits’. For hospitals experiencing demand resources focus is on patient care, with containment of radiation by clothing control

IS #16


Understand the Radiation TReatment, TRiage, and TRansport system- RTR and use this terminology when communicating with EMS.

IS #3


Work with ICS to determine status of MC facilities, including alternate care facilities, and AC- , to where people without immediate medical needs will be directed.



Use REMM for assessment of radiation injury

IS #11


Work with EOC for receipt of supplies from SNS.



Begin treatment of obvious radiation casualties 2-6Gy with bone marrow growth factors based on supply, demand and triage plans.



Determine need to transfer patients and available transportation means with EMS – facilities closer to the blast may need medical helicopters to ferry supplies and staff in and evacuate limited numbers of moderate/critical patients already stabilized


Public Health


Implement orders for Sheltering-in-Place initially as determined in discussion with EM, DHS, HHS and other radiological response teams.

IS #7


Request any emergency health powers declarations as needed under local/state law



Based on field reports and in conjunction with EM and Federal advice, begin to define Dangerous Fallout areas, rates of decay, and develop recommendations for evacuation timeframe for those sheltering in place. Define evacuation points and assess evacuation routes.



Provide public messaging about self protection and who should NOT go to a medical facility, in order to allow resources to be used for seriously injured.

IS# 11


With EM, plan and open AC for minor care / shelter and communicate these resources to public. Provide support for shelters and alternative Medical Care locations.

IS #3


Participate / liaison with HMCC to assess medical system condition and needs



Notify MRC volunteers including adjacent jurisdictions/regions and begin assignment to AC, MC, and shelter sites



Assure reception site for SNS materials activated and determine incident impact on usual distribution plans to healthcare facilities, determine delivery to AC and MC sites depending on plans for myeloid cytokines administration



Based on identified areas of radiation, develop / modify a screening form for use at shelters, AC, and MC sites that collects basic demographic data, epidemiologic data, and symptom/timeframe information.



Develop identification plan / tracking plan for those receiving myeloid cytokines (e.g. wristbands)



Activate victim tracking system

IS #6


Activate family reunification hotline and other resources – request national American Red Cross information line activation

IS #10


Provide instructions for public on self-decontamination - who needs it and how to do it (include instructions for pets)

IS #16


Recommend personal protective measures and equipment for citizens and responders.



Activate mass fatality plan.
Inform public that saving lives and providing care to living are first priorities.

IS #7
IS #11

Medical System Response


Notify area facilities of incident and provide updated information as needed



Activate Health and Medical Coordination Center plans including liaison to multi-agency coordination center or EOC



Obtain situation status information including healthcare facilities with structural damage, functional status of those facilities, access issues to those facilities, and patient loads at area facilities. Create hospital situation report for public health.



Activate resource sharing plans as needed



Determine, with public health, location of Medical Care and Assembly sites and organize staff and materials for these sites including use of regional resources and MRC



Assist overwhelmed hospitals by obtaining buses or other transport as possible from EOC and by ferrying in staff and supplies (may need to be done via helicopter)



Receive resource requests and identify policy issues requiring guidance



Prepare inventory of requested medical supplies and activate local strategy for obtaining them

IS #11
IS #9


Anticipate delivery of SNS and other resources on 24h timeframe and work with public health to deliver to facilities in greatest need first



Assist PH with public message development about when/where to seek care



Coordinate resource requests with EOC critical to minimize duration of time spent in Scarce Resource situations.



Use REMM as a resource for patient care

IS #11


Develop provisional information for hospitals on dangerous fallout locations and circulate triage criteria for myeloid cytokines and medical treatment toward end of operational period. Be prepared to update this information to reflect situation.



Assure National Disaster Medical System (NDMS) activated and instruct overwhelmed hospitals to begin to prepare lists of patients for evacuation.



Provide basic information on ‘dry decon’ to clinics and other healthcare facilities and request personnel as needed to support acute care needs at hospitals and Medical Care sites



Consider need for Federal Medical Station or other alternate location for hospital overflow



Consider need for Disaster Medical Assistance, Burn, and other specialized teams and personnel – communicate needs to EOC



Provide basic information on ‘dry decon’ to clinics and other healthcare facilities and request personnel as needed to support acute care needs at hospitals and Medical Care sites


Evacuee Medical Care and Fallout-related Radiation Illness


Shelter-in-place initially, evacuate based on official advice.



Provide instruction on decontaminaton. Self-decontamination is only necessary for those with fallout contamination on them. Listen for information of where fallout is and IS NOT.

IS #16


Remind victims via public messaging to remember physical location and time spent there. This is critical for dose estimation and triage.



Instruct and/or move evacuees to Assembly Centers (AC) set up by PH with support from other agencies. Utilize portal or other screening at “clean” ACs for contamination, provide at least dry decon for those contaminated if possible.



Evaluate for injuries and symptoms related to exposure



Refer injuries to hospital or Medical Care location (may be co-located with Assembly Center) as necessary, accounting for local hospital ability to provide care



Register those at assembly center – complete screening sheets if available toward end of operational period



Refer asymptomatic individuals to area shelters



Treat symptoms (mainly vomiting) of Acute Radiation Syndrome (ARS), provide cytokines ( myeloid cytokines) to those with vomiting if available from local stores




Define areas that will have NO radiation and remain useable. Emphasize that there is no need to evacuate these areas.



Emphasize community resilience and individual actions to assure personal safety and health



Define requirements for victim registry personnel in conjunction with Federal officials (DHS, HHS)



Activate psychological support teams for responders.

IS #13


Begin to identify priorities for utility service restoration in Light Damage Zone


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  • This page last reviewed: February 14, 2012