For many years, federal, state, and local authorities throughout the United States have planned and trained for the notional possibility of a 10-kiloton improvised nuclear device being detonated within a major metropolitan area. If that were to occur, the hundreds of thousands of fatalities and life-threatening injuries that may follow would severely challenge, if not overwhelm, all components of any healthcare community – especially hospitals.
Considering this scenario, within the first 24 hours after a detonation, all hospitals in and around the blast area will face numerous response issues. To help determine the possible extent of the damage and need for assistance, most experts agree that there are three distinct blast-damage zones created when a nuclear detonation occurs: (a) a severe damage zone; (b) a moderate damage zone; and (c) a light damage zone.
The severe damage zone encompasses the area immediately surrounding the detonation site, and extends to a radius of about 0.5 mile. Damage in this area will be extensive, with few if any above-ground buildings remaining structurally sound and very few persons within the zone surviving. In addition, high radiation levels would pose an ongoing danger to any survivor or responder within the zone.
The moderate damage zone adjacent to and surrounding the severe damage zone extends to a distance of about one mile from ground zero. Some reinforced concrete buildings may remain standing, but most lighter commercial and residential buildings would collapse, thus trapping and possibly killing anyone inside. In addition to the blast injuries suffered by any survivors, there also would be significant fallout of radiation particles that, along with the extensive dust clouds created, could cause serious medical problems.
The light damage zone surrounding the moderate damage zone extends to about three miles from ground zero. The overpressure wave created by the detonation will likely cause somewhat less severe structural damage in this zone, but still lead to numerous injuries and fatalities caused by flying debris. Although the radiation levels in this zone tend to be lower than in the severe and moderate damage zones, there may be isolated areas of concentrated danger. Moreover, many survivors in this zone will likely suffer from extensive soft-tissue and orthopedic injuries, ruptured eardrums and abdominal organs, and/or flash blindness.
Hospital Response & Incident Command Issues
The detonation of a 10-kiloton improvised nuclear device obviously would have a profound and extremely adverse effect not only on the healthcare facilities in the immediate impact area but also in areas farther away. More specifically, if the facilities in the severe damage zone were totally destroyed and those in the moderate damage zone were severely damaged and facing evacuation, the facilities in the moderate and light damage zones that do remain open, and fully functioning, would undoubtedly confront a series of rapidly intensifying administrative, operational, and resource-management response issues.
The hospitals in this last category would have to quickly implement an incident command system (ICS), using whatever trained personnel are immediately available to fill vital command positions. Off-hour responses obviously could be further complicated by traffic congestion and the disruption of normal transportation systems, thus delaying and sometimes preventing numerous hospital personnel from being able to return to work in a timely manner.
Any plans developed to establish and maintain the ICS must address the continuing need – for days, if not weeks – to staff all essential command positions. Moreover, initial and ongoing decision making depends on the receipt of accurate and comprehensive situational awareness reports provided by public safety and emergency management officials, who themselves may be seriously challenged in their efforts to maintain an effective and complete grasp of the situation.
Notwithstanding such challenges, the principal response objectives for each operational period will necessarily focus on: (a) meeting the physical and behavioral health needs, under extremely austere conditions, of a large number of seriously injured patients; (b) continuing facility operations within a potentially contaminated environment; and (c) maintaining health and safety standards as well as those related to facility security.
The hospital’s incident management team, previously selected and trained, will be further burdened by the need to share information on a continuing basis not only with other healthcare facilities, in accordance with established protocols, but also with local health and emergency management officials, particularly those in the nearest Emergency Operations Center (assuming one is operational).
Corporate headquarters officials also must be kept informed, if the hospital is part of a corporate healthcare system. Complicating all of these communication efforts and the operation of other electronic equipment – including systems focused on patient care – is the possibility of an electromagnetic pulse (EMP) caused by the detonation, which could create additional direct or indirect damage within a 2-5-mile radius from ground zero. Facilities in the light damage zone that could experience an EMP disruption might be able to at least partially recover by turning the equipment off and on again and/or by installing new batteries in the systems and devices still operational.
Initial Response Operations
The initial response steps obviously will be extremely difficult; nonetheless, most would have to be taken almost simultaneously. Among the highest-priority tasks that must be carried out as quickly and safely as possible are the following (not necessarily in this order):
- Moving current patients and staff to the interior or basement areas of the facility until peak radiation levels dissipate;
- Performing a quick assessment of building integrity (structural and otherwise) to determine the possible need for partial or complete evacuation of both patients and staff;
- Determining the need to shut down heating, ventilation, and air conditioning units, and to cover air-intake vents;
- Requiring staff to don appropriate personal protective equipment, along with the personal radiation monitoring devices needed before triaging and treating patients;
- Initiating the mass decontamination of newly arriving victims by first scanning patients for radiation levels and locations and then using such information to help establish triage priorities (although lifesaving tasks normally take precedence over external radiation decontamination, facilities experiencing a large influx of contaminated victims may have to decontaminate patients prior to entry in order to keep interior radiation from rising to dangerous levels);
- Prioritizing patients for radiographic examinations, surgeries, and admission in the face of a quickly depleted bed supply (caused in part by the inability to send patients home because it is either unsafe to do so or no transportation is available);
- Addressing the ongoing needs of patients suffering from Acute Radiation Sickness (ARS);
- Establishing an “expectant care” location, with suitable staffing and medications available, to provide at least some comfort care for those who are not expected to survive their injuries; and
- Communicating early and frequently with staff and patients to provide both groups with needed information, reassurance, and instructions.
Hospitals not in the moderate or light damage zones will nonetheless find themselves confronting many of the same issues mentioned above. They should, therefore, anticipate requests to receive transfer patients from facilities in the inner zones that are either damaged and must close, or are simply overwhelmed by the huge number of patients requiring admission and/or specialty care. In some cases, particularly in the hours or days immediately following the detonation, many survivors seeking primary care for their injuries may make their own way – via emergency medical services transportation or self-directed travel – to a more distant facility.
Hospitals anywhere in the general vicinity of a nuclear detonation will quickly confront a very large number of resource management issues including, but not limited to:
- Inadequate staff because of injuries or the inability or unwillingness of staff members to report to work;
- The lack of needed medical equipment and supplies as well as medications – any of which might require activation of a “crisis standard of care” contingency plan;
- A reduced quantity of supplies because of travel restrictions, competing demands, and/or other needs that exceed the immediately available vendor supplies;
- An inability to sustain decontamination activities either because of insufficient staff or the lack of personal protective equipment and/or various other items needed to remain fully operational;
- The inability to transfer patients to other facilities because of traffic congestion and/or the lack of transportation; and
- Staff attrition, over a varying period of time, is caused by fear and/or fatigue.
To briefly summarize, the detonation of a nuclear device of any size, in any community, would inevitably have a profound series of effects on a broad spectrum of all healthcare facilities in the area, including those that survive the detonation itself. Training plans and exercises will certainly improve general preparedness for this type of incident, but the initial and ongoing patient-care requirements still would be overwhelming – and remain that way for a considerable period of time. Rapid and comprehensive regional, state, and federal assistance, in large quantities, will be required to save as many lives as possible and, while doing so, promote and support the recovery of the community’s overall healthcare system.
Craig DeAtley, PA-C, is director of the Institute for Public Health Emergency Readiness at the Washington Hospital Center, the National Capital Region’s largest hospital; he also is the emergency manager for the National Rehabilitation Hospital, administrator for the District of Columbia Emergency Health Care Coalition, and co-executive director of the Center for HICS (Hospital Incident Command System) Education and Training. He previously served, for 28 years, as an associate professor of emergency medicine at The George Washington University, and now works as an emergency department physician assistant for Best Practices, a large physician group that staffs emergency departments in Northern Virginia. In addition, he has been both a volunteer paramedic with the Fairfax County (Va.) Fire and Rescue Department and a member of the department’s Urban Search and Rescue Team. He also has served, since 1991, as the assistant medical director for the Fairfax County Police Department.