In the event of a nuclear weapons detonation, areas around the epicenter would face devastation. However, the response of a nearby medical center that remains operational is critical to saving lives and mitigating long-term health consequences. The complexity of such a disaster requires thorough planning, live exercises, coordination, and swift action. This manuscript discusses the elements of a response plan for medical centers, focusing on pre-incident preparedness, immediate response, and long-term care and recovery. The strategy incorporates both traditional emergency response protocols and measures tailored to the unique challenges posed by nuclear incidents, including radiation exposure, mass casualties, and infrastructure damage.
Local responses will be paramount, making the involvement of local and state assets, as well as coordination among all parties involved, critically important. Medical centers must maintain continuous communication with regional authorities and other health care facilities to coordinate the distribution of patients and resources. This collaboration is essential to avoid overwhelming any single facility and to ensure that patients receive the best possible care. The center may also need to provide specialized care for patients transferred from smaller or less-equipped hospitals. Additionally, public health agencies should monitor the health of the community, particularly for signs of radiation-related illnesses that may emerge days or weeks after the detonation. Although such a catastrophic disaster could result in thousands of deaths and even more injuries, collaboration between health care facilities, public health departments, specialty organizations, and communities will be essential in overcoming the crisis.
The US established response capabilities to nuclear attacks dating back to the late 1940s. The policy and doctrine found in Presidential Policy Directive #8 is the National Response Framework, the National Incident Management System, and the Federal Incident Operational Plans direct the Federal response, and the individual States develop their own policies and plans for response. A few of the US response teams and capabilities specialize in responding to nuclear and radiological incidents. Some of these teams provide critical lifesaving situational awareness, search and rescue, medical management, patient care, and medical countermeasures unique to nuclear attacks. For radiological/nuclear (R/N) incidents beyond the ability of state and local officials to manage, federal resources may available. For R/N releases from a Department of Energy (DOE) facility, DOE and/or the National Nuclear Security Administration will serve as the Federal On-Scene Coordinator (OSC). Likewise, the Department of Defense serves this role for military facilities. For other areas, Federal Emergency Management Agency (FEMA)’s Nuclear Radiological Incident Annex to the Federal Interagency Operations Plan lays out which federal agencies have lead federal agency responsibilities and may provide an OSC like the US Coast Guard and Environmental Protection Agency. In addition, federal resources can provide coordination of technical resources and equipment, in conjunction with state or other US government agencies for state, local tribal, or territorial personnel conducting decontamination through the Nuclear Emergency Support Team (NEST)1 and Chemical Biological Radiological Nuclear (CBRN) Response Enterprise (CRE).2
NEST is the primary US unit for responding to R/N emergencies.1 In a nuclear detonation, NEST provides specialized expertise to detect, analyze, and mitigate nuclear threats, managing the immediate aftermath to protect public safety and national security. NEST brings expertise in managing the medical aspects of R/N incidents and additionally educating health care, public health, and emergency management for almost 5 decades through the Radiation Emergency Assistance Center/Training Site (REAC/TS).3 This group of subject matter experts in radiation medicine respond throughout the US and internationally for all medical aspects of ionizing radiation injuries and illnesses. They maintain response capabilities 24/7 and have a long history of educating health care providers in hospital systems and other agencies such as the Veterans’ Health Administration, the congressionally mandated Radiation Injury Treatment Network (RITN), Federal Drug Administration, etc.; and educational courses globally through Northern Atlantic Treaty Organization, World Health Organization, and the International Atomic Energy Agency. These collaborative and educational efforts have helped establish the development of other networks.
The CRE, maintained by US Northern Command, is a specialized military force designed to respond rapidly to CBRN incidents, including nuclear detonations. The CRE integrates units equipped for search and rescue, decontamination, medical support, and command operations, enhancing national preparedness by providing coordinated military assistance to civilian authorities.4
The Department of Health and Human Services (HHS) has assets available. The National Disaster Medical System (NDMS) provides personnel, equipment, supplies, and a system of partner hospitals to provide care in an emergency response scenario.5 NDMS is comprised of teams of responders, including those for disaster medical assistance, trauma and critical care, disaster mortuary operations response, and veterinary response. In addition, they will ensure that approximately 2%-3% of the population will be distributed to the RITN.6 This represents the most critically injured with significant radiation exposure who would require specialized treatment not readily available at local hospitals. RITN is a network of cancer centers designed to provide specialized medical care through hematologic support up to and including stem cell transplant for victims of R/N incidents. The Strategic National Stockpile is an HHS asset that consists of stockpiled medical supplies, devices, and medications. Specific resources for responding to a R/N incident include chelating agents and growth factors/cytokines to mitigate the myelosuppressive effect of radiation exposure.
Radiation Injury Treatment Network
Since 2006, RITN has diligently worked to prepare for a distant R/N incident.7 Many communities have well exercised plans for medical surge for mass casualty incidents, and communities near nuclear power plants have well exercised plans for potential radiation exposures, monitoring, and decontamination that may be necessary in the event of an emergency. However, few communities have planned for how a distant R/N incident would impact them. Planning should consider how to respond to the medical surge resulting from a metropolitan city with an R/N incident. The likelihood of a R/N accident or R/N terrorism is relatively low for any community, but some locations may have a higher risk than others. However, all communities have a risk of being impacted by the medical surge of patients moved through NDMS8 from a distant city that is impacted by a mass casualty R/N incident or terrorist attack.
RITN is comprised of 80 stem cell transplant units in hospitals and cancer centers that are preparing to provide specialized care to patients with Acute Radiation Syndrome (ARS) following a distant mass casualty R/N incident. ARS occurs when the whole body, or a large part of it, is exposed to a high dose of penetrating radiation over a short period of time (minutes to hours). Blood cells in the bone marrow and immune system are the most sensitive organ in the body to ionizing radiation. Failure to treat ARS may result in death. Side effects of cancer treatment with chemotherapy and radiation therapy can produce a condition that closely mimics the hematopoietic effects of ARS. Consequently, transplant/hematology/oncology staff are familiar with treating ARS-like conditions.
RITN has had a long-standing memorandum of understanding with the Administration for Strategic Preparedness and Response (ASPR) in the HHS, which allows RITN to be incorporated into the NDMS for patient movement and tracking. To prepare RITN hospitals for a mass casualty incident, they are required to complete several activities annually including staff training, capacity reporting, and conducting a tabletop exercise. Since 2006, over 1000 exercises from tabletop to functional to full-scale have been conducted with support of RITN by the participating hospitals.6
Radiation Injury Treatment Network and the American Burn Association
A confounding issue with the care of patients exposed to significant doses of radiation in a R/N incident is the increased risk of combined injuries – ARS plus trauma or burns. The impact of this combination of injuries is exponentially worse than either injury on its own.Reference Brown, UU and Burmeister9 What is even more troubling is that the trauma/burn community is not well versed in caring for ARS and the transplant/hematology community is not versed in caring for patients with trauma. Since 2018, RITN and the American Burn Association (ABA) have worked to increase awareness of this critical issue and to collaborate on the development of much needed combined practice guidelines to help in the management of these patients.Reference DiCarlo, Maher and Hick10 Until these guidelines are codified, physicians in both sub-specialties will likely struggle with coordinated collaboration. The RITN/ABA vision of combined practice guidelines includes the signs and symptoms of ARS that can be used for monitoring by the trauma community, understanding the worse prognosis for the patient, and understanding who to reach out to for a consultation and support if there is not a RITN hospital in their health care coalition. On the RITN side of care, physicians will need to manage wound care in the setting of ARS and establish criteria for survivability and to be prepared to consult with the trauma community in delivering care.
Hospital System
Pre-Incident Preparedness
Pre-incident preparedness is the cornerstone of an effective response to R/N mass casualty events. The first step involves conducting a comprehensive risk assessment that identifies potential threats, assesses the proximity of the medical center to possible targets, and evaluates the center’s existing infrastructure. This assessment should inform the development of a detailed response plan, which includes evacuation routes, communication strategies, and resource allocation. The medical center should be familiar with regional evacuation plans and be prepared for an influx of patients from affected areas. The center should also participate in internal and regional drills and exercises that reflect its role in the broader disaster response. These exercises help ensure that staff is prepared for challenges such as treating patients with delayed effects of ARS and both physical and psychological trauma. Understanding their role within the larger response framework enables the center to more effectively allocate resources and personnel when a disaster occurs.
The COVID-19 pandemic exposed both weaknesses and creative solutions in handling a large influx of acutely ill patients. A critical aspect of preparedness involves ensuring that the center’s infrastructure can accommodate an increased number of patients, while securing medical supplies and expanding clinical space and staff, including all the support staff essential to hospital operations. Additionally, the center must develop protocols for decontaminating patients and staff, as well as safely disposing of potentially radioactive waste from decontamination processes. Another significant concern is whether health care workers, including clinical staff and environmental service personnel, will come to work during such a crisis. Adequate staff rotation will also be essential to maintaining patient care.
As part of preparedness, hospitals that are able should establish teams that include cross functional health care providers, such as trauma and burn surgeons, pediatricians, hematologists, oncologists, radiation oncologists, health physicists, and toxicologists. These teams should train together so that they are prepared to work together and understand their responsibilities resulting in a more comprehensive and effective response.
Each medical center should integrate into larger regional and national emergency response networks, such as the RITN. Regionally, hospitals belong to networks with a designated coordinating hospital responsible for facilitating care during an emergency. This integration involves establishing clear communication lines with other hospitals, emergency services, government agencies, and non-governmental organizations. Since 2018, the ASPR has funded 4 pilot Regional Disaster Health Response Systems in the US, covering 24 states and approximately 116 million people.5 These pilots aim to enhance health care preparedness, develop best practices, and expand medical surge capacity. A frequently cited barrier to pre-incident planning and exercises is a lack of resources. However, several federal funding programs, such as the HHS Health Care Readiness Programs and the Centers for Disease Control and Prevention’s (CDC) Public Health Emergency Preparedness program, provide financial support for such efforts.11
Staff Training and Drills
Preparing staff is essential for an effective response. All personnel from health care, ancillary, and administrative staff should undergo specialized training in managing radiation exposure, contamination, and psychological support during a R/N incident. Education and training should emphasize the identification of ARS clinical prodrome, including nausea, vomiting, diarrhea, fever, headache, and possible acute mental status change. Some training can be provided “just in time” if the necessary information is readily available and easy to use. Regular drills that simulate R/N events are also crucial for practicing staff roles in a controlled environment. These drills should include scenarios such as mass casualty triage, establishing decontamination zones, and managing communication networks during a crisis. Communication will be vital not only among various local, state, and federal agencies but also with the public. Staff should also be trained in using personal protective equipment (PPE) designed for radiation exposure, as well as having some individuals capable of operating radiation detection equipment.
Limited access to radiation emergency medicine experts at individual hospitals underpins the importance of networks like RITN, Regional Disaster Health Response Systems, and medical specialty organizations. This highlights the role of federal resources such as REACTS, which would lead the medical response to a radiation emergency. All these entities provide medical expert support to hospitals through peer-to-peer consultations, just-in-time training, education, educational resources, and clinical guidelines. An invaluable resource is the Radiation Emergency Medical Management (REMM) website (http://www.remm.hhs.gov/). REMM is a website hosted by the US Department of Health and Human Services and managed by the Biomedical Advanced Research and Development Authority. REMM is a comprehensive source of just-in-time, evidence-based information to guide health care providers about clinical diagnosis and treatment of radiation injury during R/N emergencies. The site also provides guidance for the broader health care community about issues related to planning for and responding to radiation mass casualty incidents.
Activation of the Emergency Response Plan
When a R/N event occurs, the medical center must immediately activate its emergency response plan. This includes mobilizing available staff, securing the facility, and setting up triage and decontamination stations. Initially, the focus should be on managing the influx of casualties, which may include individuals with traumatic injuries, burns, and radiation sickness. Triage teams should assess the severity of injuries and prioritize treatment based on the likelihood of survival. The extent of patient influx will depend on the distance from the epicenter. Medical centers closest to the blast, if still operational, will receive most casualties. Given the expected high volume of patients, the center should implement a triage system categorizing patients into 4 groups: immediate, delayed, minor, and expectant.Reference Hick and Coleman12 This allows for the most efficient use of limited resources. In this setting, it is anticipated that altered standards of care will be authorized by federal, state, and local authorities. Centers should have procedures in place that have been vetted by leadership and ethical oversight committees. HHS has resources available to assist in developing such plans.13
Centers farther from the epicenter will still face a high influx of patients but will have more time to prepare, including establishing secondary care centers such as ad hoc field hospitals. Real-time communication between hospitals about capacity and capabilities is essential. Several states have implemented or are developing Medical Operation Coordination Cells to assist in directing patient transfers and ensuring hospitals with available beds are utilized during surge conditions.
Decontamination and Radiation Management
R/N events present the unique challenge of potential radioactive contamination of patients, staff, and medical facilities. To prevent the spread of radiation, decontamination zones must be established outside the facility, equipped with showers, PPE, radiation detectors, and methods for capturing contaminated clothing and water. Patients arriving at the center should be assessed for radiation exposure using walk-through or handheld detectors. Those with significant contamination should undergo decontamination after life threats have been addressed. Dry decontamination efforts removing contaminated clothing will be most effective for mass populations; however, additional clothing must be supplied. Focused moist or mass casualty shower facilities may also be used. Staff must follow principles of limiting time around the contaminants, using distance when possible and shielding (i.e., PPE). It should be emphasized that radiological contamination should not be managed as chemical contamination, which may be deadly to the health care team if immediate decontamination is not performed. Cumulative radiation doses received by staff should be tracked with monitoring devices. Hospitals should also coordinate with state radiation control programs to access their expertise and resources for radiation assessment and protection. Community Reception Centers (CRC) operated by local and state departments of health will monitor for radioactive contamination. These centers are typically operational 24-48 hours after an incident. The CDC has published guidelines for population monitoring in CRCs.14
Medical Treatment and Triage
The primacy of instituting life-saving measures is a core principle in the initial treatment of all patients from an R/N incident. It can be expected that following such an incident, casualties may suffer from isolated radiation injury, isolated blast injury, isolated thermal (burn) injury, or a combination of trauma mechanisms (often referred to as combined radiation injury). In the immediate aftermath of a R/N event, the first medical priority is to immediately address life-threatening injuries such as hemorrhage, pulmonary failure, and cardiac failure to the extent medical capabilities can support such efforts. Because R/N events have the potential to create massive numbers of casualties, medical centers may quickly find that medical specialists, supplies, and bed availability are overwhelmed. If the medical center is to provide the greatest likelihood of survival to the greatest number of casualties, it must honestly evaluate the extent of its medical capacity and institute triage criteria that will focus scarce medical resources on a select subset of casualties.
Triage of isolated physical trauma patients in crisis conditions are commonly included in medical center mass casualty plans. The pathophysiological impact of acute radiation exposure on trauma patients imposes additional complexity to the triage process. In general, whole body radiation exposures of >2 Gray (Gy) are expected to significantly increase trauma casualty mortality and must be considered in assigning triage categories. A good reference for triage category assignment for casualties with combined radiologic trauma can be found in Coleman et al.’s, Triage and Treatment Tools for Use in a Scarce Resources-Crisis Standards of Care Setting After a Nuclear Detonation. Reference Coleman, Weinstock and Casagrande15
Biodosimetry is the use of physiological, chemical, or biological markers of exposure of human tissues to ionizing radiation for the purpose of reconstructing doses to individuals or populations. Currently, the gold standard is the dicentric chromosome assay,Reference Blumenthal, Sugarman and Christensen16, 17 which is only performed by a few laboratories in the US and is not field-deployable, limiting its use in mass casualty situation in the first days of the aftermath. Lymphocyte depletion kinetics can be useful when serial complete blood counts are available for an individual patient. There is great interest in the development of practical biodosimetry assays for R/N mass casualty events, and this has been the subject of much researchReference Satyamitra, Cassatt and Molinar-Inglis18 and some of these projects have reached advanced development stages.Reference Capaccio, Perrier and Cunha19, Reference Iversen, McCarthy and Burdett20 However, there are currently no FDA cleared biodosimetry assays for that indication. Highly sensitive and specific biodosimetry will be critical to long-term population monitoring.
Once acute life-saving interventions have been completed, medical center providers must begin to assess and establish a treatment plan for patients suffering from ARS. ARS and the failure of bone marrow and other stem cell production that usually clinically presents days to a few weeks after significant radiation exposure. This will drive the need for specialized care, including administration of hematopoietic cytokines, anti-emetic drugs, antibiotics, irradiated blood transfusions, and possibly stem cell transplants in select cases. Care should be taken to triage the radiation injured population to ensure those at receiving an estimated 2 Gy or higher dose are considered for treatment with colony stimulating factors (if possible, within the first 24 hours of injury). To utilize limited inpatient bed spaces most effectively, medical staff should develop criteria to determine which radiation casualties may be safely managed as outpatients. In addition to hematologist/transplant physicians and burn/trauma surgeons, the care of these patients will require a team of physicians. Chronic medical illnesses and new medical problems developing due to their exposure will need to be managed and included in decision making about their ability to survive.
Given the potential for overwhelming patient numbers, the medical center must coordinate with other hospitals and emergency services to distribute the load. This may involve transferring fewer critical patients to other facilities and using telemedicine to provide remote consultations. For isolated radiation casualties, RITN member hospitals, as discussed, have established processes to regulate and facilitate transfer to medical centers equipped and staffed to provide definitive care for radiation injured patients. Tracking patients and transmitting their medical information as they move from the site of an incident through immediate care facilities and on to more specialized treatment facilities is another challenge.
Long-term Care and Recovery Ongoing Medical Care
The long-term effects of a R/N event may require sustained medical care for survivors. Patients may face chronic health issues, including cancer, organ damage, and psychological disorders. The medical center should collaborate with local and state public health agencies to establish long-term care plans for affected individuals, which may include regular monitoring, rehabilitation, and specialized treatments. Radiation-induced cancers are a significant concern. Medical centers assist in setting up screening programs to monitor for early signs of cancer in exposed individuals, including regular blood tests, imaging studies, and genetic counseling. Coordination with public health departments and cancer registries will be important to track new cancer cases and long term follow up occurs for the life of the affected individuals. Regionally or nationally, a network of outpatient clinics for long-term monitoring could be established, like the World Trade Center Health Program.Reference CfDCa21 Following the 2011 disaster at TEPCO’s Fukushima Daiichi Nuclear Power Plant, the Fukushima Prefectural Government initiated the Fukushima Health Management Survey (FHMS).22 The FHMS is comprised of a basic survey (external dose estimation for the first 4 months after the nuclear accident) and 4 detailed surveys (thyroid ultrasound examination, comprehensive health check, mental health and lifestyle survey, and pregnancy and birth survey). This is an ongoing effort with no defined end date.
Psychosocial Support
Mass casualty events, whether natural disasters or deliberate terrorist actions, can lead to a variety of psychological traumas in survivors, first responders, and caregivers-Reference Lowe and Galea23-Reference Moreland, Rancher and Davies26 R/N events carry an additional burden for victims. Rather than an immediate community reaction of empathy and support, they may be shunned due to unfounded fears that they have become permanently contaminated. Lessons learned from the Goiania Cesium-137 incident highlight the long-term mental health impacts of radiation-related stigma, which affected the community for years.27 The Fukushima nuclear disaster triggered a long and widespread evacuation, which secondarily caused the discrimination and bullying of evacuees due in part to them being perceived as “radioactive.”Reference Harada, Kawabata and Joel28 Follow up studies in Fukushima evacuees have shown that those who adopted an “action-oriented approach,” such as setting positive new goals and maintaining good relationships with others, had better mental health outcomes.Reference Takebayashi, Maeda and Orui29, Reference Kobayashi, Maeda and Nakayama30
The center should also be prepared to manage psychological trauma, as survivors may experience acute stress reactions, anxiety, and post-traumatic stress disorder. Mental health professionals should be on hand to provide immediate psychological first aid and to support long-term recovery. These mental health providers should also be on hand to help the medical staff taking care of these patients. A unique social support and mental health challenge following a R/N incident will be the coordination required to keep families together, especially those with young children, when most or even all have suffered radiologic or traumatic injury.
Building community resilience is essential to recovery. The medical system should play a central role in providing psychosocial support to survivors, their families, and the broader community. Counseling services, support groups, and community workshops on coping strategies and resilience-building should be offered. Engaging local leaders, schools, and religious organizations can help build a network of support that extends beyond immediate medical care, fostering collective recovery. Reducing stigma and supporting mental health are key components of long-term recovery. Finally, the medical center should review and update its emergency response plan based on lessons learned from the incident, ensuring continuous improvement and better preparedness for future emergencies.
Institutional Resilience
Cold War medical preparedness programs were focused on widely distributed capabilities that were placed in the hands of local medical personnel to act when needed. The Packaged Disaster Hospital program placed 200-bed hospital capabilities to be established outside of likely target areas, often in school buildings. Hospital Reserve Disaster Inventory sets placed a 30-day supply of common supplies (focused on trauma and burns) for each licensed bed in existing hospitals in these areas. In the early 1980s, the NDMS program evolved from FEMA recognition of the loss of cold war era preparedness programs. Another component in the creation of NDMS was the Civil-Military Hospital Coordination Program. This program was created by the military out of recognition that shrinking military inpatient capabilities would be unlikely to support the numbers of patients that could result from a major conventional war overseas.31
Contemporary medical preparedness programs changed to focus on deploying limited, highly equipped reservist teams, such as the Disaster Medical Assistance Team or the Disaster Mortuary Operational Response Team, or just-in-time delivery of supplies from centralized warehouses in order to limit scope and cost. The SARS-CoV-2 pandemic demonstrated the limitations of both methodologies. It is very difficult to deploy personnel from home areas that have their own requirements, potentially causing more harm than good. Centralized stockpiles are not available quickly when events occur and are quickly consumed by large-scale needs. Building resilience in medical systems for even an isolated R/N incident will require lessons learned from both the past and recent experiences.
Conclusion
A R/N incident represents one of the most challenging scenarios a medical system can face. Effective response requires thorough preparedness, coordinated action, and sustained long-term care. By investing in risk assessment, staff training, resource allocation, and infrastructure resilience, medical centers can enhance their ability to manage such crises. Immediate responses should focus on triage, decontamination, and trauma care, while long-term efforts must address chronic health issues, environmental contamination, and community recovery. Through comprehensive planning and collaboration, medical centers can play a crucial role in mitigating the devastating effects of a R/N incident upon a civilian population center and aid the recovery of affected populations.
Acknowledgements
Supported by National Institute of Allergy and Infectious Diseases of the National Institutes of Health under Award Number U19AI067798, Department of the Navy, Office of Naval Research Grant #N00014-10-1-0204 to the National Marrow Donor Program.
Competing interests
The author(s) declare none.
Open access
