US cities are not medically prepared for a nuclear attack: Bulletin of the Atomic Scientists.

US cities are not medically prepared for a nuclear attack: Bulletin of the Atomic Scientists. (BAS). HT: Crof.

The abstract:

The United States is not prepared to deal with an attack by a terrorist group using an improvised nuclear device, the author says. It should get prepared, because the risk is real even if the probability is low, and doing so could save a great many lives. 

The author explores the potential impact of a 10–15-kt improvised nuclear device set off in New York City. The initial blast would kill between 75,000 and 100,000 people in seconds. Another 100,000–200,000 people would be injured, many of them dying within weeks or months, some with burns, others with impact injuries, and some with acute radiation syndrome. 

The demands on the medical system would be vast and overwhelming, all the more so because the bomb would have destroyed much of the capacity to respond. Current planning efforts are not sufficient to manage the carnage.

What we’re up against.

There are four types of potential nuclear incidents that require some level of preparation: an accident or attack at a nuclear power plant, a dirty bomb, terrorist use of an improvised nuclear device, and an attack using a nuclear weapon executed by a foreign nation. The first two types of events – an incident at a nuclear power plant and a dirty bomb – have received a greater level of planning attention than the others. An attack on a nuclear power plant or a catastrophic accident like the ones that occurred at Chernobyl in 1986 and Fukushima in 2011 would have devastating short- and long-term effects. With that in mind, the Federal Emergency Management Agency (FEMA) and Department of Energy require that states with nuclear power plants practice notification, response, and evacuation plans. Zones requiring specific actions have been designated depending on communities’ proximity to nuclear power plants. Fortunately, the track record of the US nuclear power industry has been reassuring in terms of planning for accidents. The possibility of a dirty bomb attack has also received planning attention from US authorities, in part because it is seen as relatively likely on the spectrum of nuclear disasters. A dirty bomb is a rather simple device composed of a conventional explosive – much like the one used to blow up Oklahoma City’s Alfred P. Murrah building in 1995 – laced with radiological materials called isotopes. Gaining access to radioactive isotopes is not as challenging as one might expect. Medical facilities use various types for diagnostic testing, and several industries require them. Certain isotopes, while difficult to come by, have a long half-life, and if used in a dirty bomb would contaminate the blast area and that around it with residual radioactive material for months or years. This would create a “hot zone” too dangerous to enter for any type of firefighting, rescue, or reconstruction activity. Additionally, radioactive particles dispersed in the air can be carried downwind in a “plume” and deposited far from the explosion. Planning for the aftermath of a dirty bomb will vary from city to city. Most cities have some level of preparedness for  managing a mass-casualty event, but the problem of radiation contamination adds complexity. The majority of contamination can be handled by removing clothing and washing victims’ skin. Once victims are removed from the area, the residual ground and building contamination is a less urgent problem, and decisions about clearing the area will likely be made by city authorities in conjunction with federal agencies.

The most devastating kind of incident would involve a nuclear weapon: Terrorists could acquire or build and detonate an improvised nuclear device in a major city, or – worse because the bomb would be bigger – a foreign nation could launch a nuclear attack. In the first scenario, the device would likely be between 5 and 10 kt. A 10-kt bomb would release the same amount of energy as 10,000 tons of TNT. The kind of improvised nuclear device we are most likely to see is a “gun” type of bomb that would use an explosive to fire a mass of HEU through a tube at another mass of HEU, causing fission and the release of energy in an eruption of pressure, light, and heat. A 10-kt improvised nuclear device would destroy or significantly damage everything within a half-mile radius. An attack by a government with a long-standing nuclear weapons program could be orders of magnitude worse.

The strength of the explosion could range from something around 10 kt – the size of a nuclear bomb North Korea tested in 2013 – to measurements in the megatons, or hundreds of times greater. In a nuclear attack, the bomb will be dropped from an aircraft or delivered via missle. Unlike a bomb carried into a city on a truck, a bomb delivered by air can be detonated above a city rather than at ground level, causing a larger area of destruction and loss of life. In the discussion that follows, I make the assumption – based on information from open-source material – that terrorists are unlikely to construct a device greater than 10 kt, and that a missile launched by North Korea would carry a warhead in the 10–15 kt range. These scenarios are both more likely than a multimegaton nuclear warhead being launched at the United States. What to expect For those who must think about planning for the aftermath, one of the starkest facts about a nuclear bomb attack is that on top of killing people on a vast scale, it will thoroughly destroy the capacity to respond.

When a nuclear bomb made with HEU detonates, it releases an enormous amount of energy of four different types. The blast releases 50 percent of its energy in the form of a pressure wave so powerful that it levels buildings. There is little chance for human survival within a quarter mile, and as the wave travels farther out and weakens, it can shatter glass within half to three quarters of a mile. Thirty-five percent of energy from the blast creates the blinding flash, emitting heat that incinerates all but concrete buildings (and melting glass and burning the contents even in those). Fires will be so numerous and radiation levels so high that firefighting will be impossible. Initial (or “prompt”) radiation accounts for 5 percent of the energy. The remaining 10 percent is released in long-term fallout or residual radiation, which can, when carried by wind, travel over long distances. Should an improvised nuclear device detonate in New York City’s Times Square, the initial blast will kill between 75,000 and 100,000 people in seconds. They will be incinerated so thoroughly that their ashes will be indistinguishable from the ashes of the buildings around them. Others will be crushed by falling buildings, struck by flying debris, or thrown by the pressure wave against buildings, the ground, or each other. Another 100,000–200,000 people will be injured, some with burns from the heat of the blast, others by objects hurtling through the air. Many will be exposed to various levels of radiation that will cause suffering or death over weeks and months. The loss of city government, fire and police departments, and other emergency responders, coupled with demolished hospitals and destroyed water, sewage, power, and gas lines, means that repairs will take months or years even outside the contaminated “hot zone” and be impossible within it. The city will become a ghost town. As a result of the plume carrying radioactive particles downwind, hundreds of square miles may be unusable and need decontaminaion.

 People will leave their homes in search of safe havens. With no radios to give them instructions, some will move into the path of the plume and be exposed to a higher dose of radiation than they would have received had they stayed home. Many of these evacuees will die from radiation exposure. Chaos will prevail as millions of people try to evacuate the city without aid of communications systems, which will have been destroyed. They won’t know where to go or where to receive medical care. Following a hurricane, people can reach shelters, medical teams, and sources of food and water that were deployed in advance. Following a nuclear attack, none of these assets will have been prepositioned prior to the explosion. In the early 1980s, while living outside of Boston, I received a pamphlet in the mail instructing me to evacuate to a specific town should the worst happen. A reporter following this effort to prepare citizens traveled to several of the “host” towns to determine their readiness to receive all the evacuees. The reporter was startled to find townspeople who said the new arrivals wouldn’t be welcome. Where would city evacuees go if an attack occurred today?

From 2009 to 2010, as part of research I was doing for the Defence Academy of the United Kingdom, I conducted an end-to-end assessment of the medical capabilities of several countries and cities to respond to terrorist use of an improvised nuclear device. (It was similar to one I completed while serving as director of the Mayor’s Office of Emergency Management in New York City, looking at the aftermath of biological and chemical attacks.) No city or country visited during this assessment was prepared to manage the aftermath of a nuclear detonation. Even taking into account just the medical needs of a large city following a nuclear attack, the results clearly showed that current planning efforts were not sufficient to manage the carnage.

 Using New York City as a model, it’s anticipated that several hundred thousand people will require some sort of medical evaluation or care. With the loss of hospitals and 35–50 percent of first responders, and health care personnel unable or unwilling to go to work, surviving hospitals will need to use every inch of space to treat only the most critically injured. Makeshift treatment centers or casualty collection points near the blast will be required to triage the injured. Ethical and moral issues will arise as the overwhelmed staff, short on supplies, is forced to decide who should receive treatment and who should be moved to end-of-life care, receiving morphine to ease their pain. The profound psychological impact on these healthcare workers and first responders cannot be overstated. Their task is essential, though: The ability to make some order out of the chaotic wave of people with different levels of injuries, from those with various kinds of physical trauma to those with psychological trauma to the “worried well,” is a key to reducing morbidity and mortality. Certain characteristics of nuclear attacks make them especially hard to prepare for. A nuclear blast causes an electromagnetic pulse that knocks out communication systems, some irreversably. Without the ability to communicate, coordination among medical personnel and other first responders will become nearly impossible.

Assuming medical staff can get to where they need to be, demand for them will be extraordinary, but managers will have to rotate them to prevent exhaustion and reduce the psychological impact. There will be an overwhelming number of patients. After triage, some will have to be transported. Hospitals will have to not only care for the injured but also control security and coordinate the flow of information to victims’ families. Local, state, and federal governments will have to rapidly set up alternate-care facilities close to the “hot zone.” They will have to have plans for alternate standards of care, so that, for example, emergency medical technicians are allowed to perform tasks ordinarily reserved for paramedics or nurses, freeing paramedics and nurses to perform more advanced medical treatment than normally permitted. This last issue, the focus of numerous studies and reports, presents both legal and ethical challenges, many of which need to be resolved in state capitals, where the scope of practice for health care professionals is typically controlled. And planners should remember that just because an ethical issue is resolved in advance, doesn’t mean that the decision will be followed in practice in the aftermath of a disaster. Sending an adult to end-of-life care may pull on the heartstrings, but sending a child to the same fate could prove to be too difficult for many medical personnel.

Beyond the difficult front lines of triage, survivors of a nuclear explosion will have a variety of injuries, some well known to modern hospitals but others more difficult to diagnose and develop a plan for. Acute radiation syndrome, in particular, results from exposure to radiation and does not have to coincide with any other injury. It may be the only effect a survivor suffers, and it may not manifest soon after exposure. Acute radiation syndrome occurs when a significant portion of the body is exposed to a large dose of penetrating radiation in a short period of time. The nature of acute radiation syndrome depends on the dose. At lower doses, the only effect may be on the gastrointestinal system and bone marrow. At higher doses, bone marrow will stop producing infection-fighting white blood cells, platelets that assist in blood clotting, and red blood cells that carry oxygen. Larger doses also destroy the lining of the gastrointestinal system, causing diarrhea, vomiting, and an inability to swallow or digest food, requiring patients to receive nutrition and fluids intravenously. At the highest levels of exposure, the heart and nervous system are impacted and rapid progress toward death is certain. Some of the most difficult patients to manage are those with combined injuries – say, a penetrating wound from a shard of glass, requiring rapid surgical intervention, and also acute radiation syndrome. Finally, a great moral and societal challenge will be managing the dead. Many victims will be in the “hot zone,” where responders can’t enter and radiation levels may not be safe for years. Victims’ families, though, will demand recovery of loved ones. Even where identifiable remains exist, the number of dead will be so large that months may pass before a family receives them. At some point in recovering bodies, a decision may have to be made to bury victims in mass graves. The United States has excellent systems in place to manage mass fatality incidents – but they have never been tested with several hundred thousand dead at one time.

Where do we stand?

These issues have not received enough attention from FEMA, the US government entity responsible for helping states plan for and respond to disasters. FEMA takes what emergency planners call an “all hazards” approach, meaning it addresses effects common to many different types of disasters. This lack of planning to deal specifically with a nuclear incident is a serious weakness.

That makes it all the more important for states and cities to have their own plans in place for worst-case scenarios. It’s far easier to scale back a response if resources are not needed than to need them but not have them. While serving as Commissioner of Homeland Security and Emergency Services for New York State, I asked each of the 57 counties to plan for what they thought to be a worst-case scenario. (Scenarios varied from county to county.) Where FEMA has lagged, the US Department of Health and Human Services has aggressively built up its capability to respond to a nuclear incident. It has medical response teams that are staffed and equipped to mobilize in response to an incident, support state and local governments, and, depending on what is needed where, either provide comprehensive health care infrastructure or augment existing hospitals and clinics. In the aftermath of Hurricane Sandy in 2012, these teams provided the only medical care available to some communities on Long Island, just east of New York City. They provided invaluable aid in evacuating Manhattan hospitals. The Department of Health and Human Services has also committed significant resources to acquiring medical treatments for the survivors of a nuclear detonation. The Strategic National Stockpile, composed of 12 separate units at classified locations around the country, is also under the department’s control, and capable of being dispatched to any city within 12 hours. In it are supplies to treat burn injuries, as well as cutting-edge therapeutics to aid in reversing the effects of radiation by stimulating bone marrow to produce platelets (which help stop bleeding) and white blood cells (which help prevent infection). Should respirators be needed, the Strategic National Stockpile can provide them, along with antibiotics, vaccines, and massive quantities of intravenous solutions. Many units from the stockpile will be needed to support a city in the aftermath of a nuclear detonation.

Cities far from the nuclear blast are also a potential resource. The federal government is sure to ask for help from far afield as soon as demand for medical resources exceeds local supply in a given area. Governors and mayors may be reluctant to release personnel, though, either for political reasons or out of concern that their cities and states may be targeted next. I believe most elected officials will rise to the occasion, and dispatch as much help as they can spare. But no number of simulated incidents can predict how political dynamics will shift following the real thing. Over the course of the study I conducted in 2009 and 2010, several government officials said they were unable to take steps forward because the elected officials they reported to were unwilling to discuss the issue. Privately, many politicians used to worry that if they discussed nuclear terrorism, they would likely be ridiculed for fearmongering. In the last seven years, that concern has changed dramatically at the national level, with President Obama and other world leaders convening to address nuclear proliferation and nuclear terrorism. Silence at the local level continues, though. Among city and state governments, the only ones that I’m aware have some level of ongoing planning for nuclear disaster are New York (city and state), Washington state, Los Angeles, Boston, and Chicago. To a much lesser extent, several more cities are engaged as well. The state of Hawaii has asked the federal government for assistance in planning for a nuclear attack. Read the full story here.