| Emergency Medicine
After a Nuclear 911
by Steve Daniels*, M.D., August 28, 2003
I have been asked to comment on the
medical response to ³The Day After the Day After,² that
is, a deliberate terrorist attack against the U.S. population
and/or infrastructure by terrorists utilizing nuclear materials.
A few caveats are in order. First, my predictions of damage and
plausible medical response are estimates, featuring a range of
possible consequences. However, I feel that these are realistic
estimates, based on data from atomic weapons tests, the U.S. attacks
on Hiroshima and Nagasaki in 1945, nuclear power plant accidents,
and responses to other non-nuclear mass casualty incidents. I
have a bibliography of sources for my talk available to anyone
who is interested. Second, my remarks will not include evaluation
of probable environmental, political, economic, or psychological
effects, all of which certainly will impact any emergency medical
response. Those effects will be covered by other speakers. It
is important to understand that all those various effects would
be additive in completely unpredictable ways. Thirdly, my remarks
will be addressed to the scenario of a single attack, or at most
a few simultaneous attacks; in other words, not relevant to a
nation-vs.-nation exchange of nuclear weapons, which is an almost
unimaginable catastrophe threatening the existence of all life
on the planet. Finally, there are differing potential modalities
of terrorist nuclear attack against the U.S., including:
- Attack on the transport by truck or train of
nuclear waste , to steal the nuclear material for further use;
- Detonation of a so-called ³dirty² bomb,
which is a conventional explosive deliberately contaminated with
radioactive material to cause dispersal of that radioactivity;
- Physical takeover of a nuclear power plant by
intruders, with subsequent intentional interference with plant
operation leading to a ³meltdown² of the core and release
of radioactivity;
- Detonation of a conventional weapon, delivered
by motor vehicle, boat, or airplane, at a nuclear power plant;
- Explosion of a thermonuclear bomb.
Because of time constraints and the particular
focus of this conference, Iwill limit my remarks about medical
response to the latter two scenarios: that is, conventional weapon
explosion at a nuclear power plant, and, principally, explosion
of a terrorist nuclear bomb.
In order usefully to understand possible emergency
medical response to those scenarios, it is necessary to review
what comprises emergency medicine at this time in the U.S. Our
medical system is one of the most technologically advanced in
the world. A corollary is that U.S. emergency medicine depends
on a technological infrastructure, which distinguishes it from
Third World medicine, featuring simple intravenous fluid therapy,
pills, and few facilities with often limited accessibility and
affordability, and from rudimentary ³medicine,² or basic
first aid. Although our own medical and public health systems
are currently tenuous and in increasing jeopardy, nonetheless
they still feature and will continue to feature the following:
- Hospitals in communities of all sizes, with designated Emergency
Rooms ;
- Trained specialists, including Emergency Physicians,
Registered Nurses, laboratory technicians, radiology technicians,
and the clerks, housekeeping staff, and other ancillary personnel
without which they could not operate;
- An infrastructure consisting of electric power,
clean and abundant water, and communications including telephone
and radio; - Adequate equipment and supplies, replenishable through
our transportation system of roads, vehicles, airports, and planes;
- First responders, that is, Emergency Medical
Technicians and Paramedics with ambulances, fire departments with
trained personnel, and police departments;
- Coordinating Emergency Medical Systems in every
community, responsible for maintaining readiness and reacting
to disasters. Without all those and more, we would have no functioning
emergency medicine.
SCENARIO #1: Attack
on a nuclear power plant Nuclear power plants are repositories
of huge quantities of radioactive material. The spent fuel ponds,
where used fuel rods are stored, hold 5 to 10 times the long-lived
radioactivity in the core, where energy is produced and harnessed.
A single spent fuel pond in a typical reactor holds 20 to 50 million
curies of radioactivity, represented by various radioactive substances,
most prominently radioactive iodine, with a relatively short half-life,
and radioactive cesium, with a half-life of about 30 years. A
single spent fuel pond holds more Ce-137 than was released into
the atmosphere by all atmospheric nuclear tests in the Northern
Hemisphere during more than 3 decades of nuclear
testing. A conventional explosion at a spent fuel pond could easily
dissipate the cooling water of the pond, exposing the zirconium
lining of the fuel rods to air and leading to immediate ignition.
Such a fire is inextinguishable and will burn for days to years.
During the conflagration essentially 100% of the Ce-137 and most
of the other radioactive material will be released into the air.
Its distribution will depend on weather and wind conditions. Only
two means of medical protection are available: shelter, which
will be required for all those downwind of the release for a minimum
of 2 days, up to 7 to 10 days; and ingestion of potassium iodide
orally, in pill or liquid form, which will prevent the thyroid
gland from absorbing radioactive iodine in the air. Potassium
iodide must be take before or within 4 hours of exposure to be
effective. The U.S. government has offered potassium iodide to
all residents within 10 miles of a nuclear power plant. There
is no similar substance to protect against exposure to Ce-137
or the many other radioactive substances released. When to allow
people outdoors again will depend on measurements of when the
radioactive plume has passed and how much ambient radiation remains
in the area.
Those at the plant who survive with blast injuries
may be treated as are victims of any explosion. However, treating
personnel and facilities will need protection from contamination
carried by those victims. At any rate, those victims will have
been exposed to such high radiation doses that death within a
few days is inevitable. Others, not injured by blast, who have
been exposed to more than 30 Gy (3000 rads) of radiation will
suffer effects on the cardiovascular and central nervous systems,
and develop almost immediate nausea, vomiting, and headache, followed
by seizures, shock, and death. There is no effective treatment.
Those exposed to 10 to 30 Gy will suffer damage of the digestive
system, characterized by nausea, vomiting, and diarrhea; after
an apparent brief recovery of a few days, symptoms will recur
and they will die. There is no effective treatment. Those exposed
to 2 to 20 Gy will suffer destruction of their bone marrow. After
their vomiting and diarrhea subside, in a few weeks they will
die from infection or hemorrhage unless they receive a bone marrow
transplant. Bone marrow transplantation is a complex and expensive
medical treatment requiring prolonged hospitalization and intensive
care. Only a few medical centers in each state provide such treatment.
If the power plant attacked is in a rural area, probably hundreds
of victims will need such treatment, taxing the resources of the
entire U.S. medical system. If the power plant attacked is in
an urban area, the thousands of survivors with bone marrow destruction
will have no treatment available to them and will die miserable
deaths.
There is no practical way medically to distinguish
those victims with severe radiation injury from those without,
because there is no practical way to measure absorbed radiation
dose. Thus it will be impossible for medical practitioners and
facilities to discriminate between those presenting with headache,
vomiting, and diarrhea who will die despite any medical intervention,
those with similar symptoms who will recover spon- taneously (but
will be susceptible to cancer years later), and those who are
suffering the identical symptoms from the non-organic causes of
stress, fear, and, yes, terror. In sum, an attack on a nuclear
power plant with release of radiation will potentially cause many
immediate and short-term deaths and serious injuries, untold long-term
cancers, and extreme demands on emergency medical facilities in
the involved state and surrounding states.
SCENARIO #2: A terrorist
nuclear bomb
Now for the bad news. The above scenario is trivial
in comparison with the probable effect of detonation of a nuclear
bomb. The atomic bomb which devastated Hiroshima is estimated
to have had the power of 12.5 to 15 kilotons of TNT; Nagasaki¹s,
15 to 20 Kt.
The largest thermonuclear (hydrogen) bomb exploded
had a yield of about 50 megatons; the U.S., Russia, and the other
nuclear powers have bombs ranging from less than 1 Kt to many
Mts. Given the practical constraints of acquisition and production,
it is estimated that terrorists could acquire or produce a bomb
with a yield between 0.1 and 20 Kt. For our discussion I will
postulate a weapon of 10 Kt. Such a bomb could weigh between 40
and 100 lbs., and be dropped from a plane or brought into a city
by suitcase, car, or shipping crate. The most likely terrorist
target would be a large city; for example, Los Angeles. Atomic
bombs destroy by several effects: Blast, usually comprising the
release of about 50% of the bomb¹s energy; Thermal radiation,
both heat and light, comprising about 35% of the bomb¹s energy;
Radiation, about 15%, involving both short-term and long-term
damage, as we have already seen in discussing the first scenario;
Electromagnetic pulse. Bombs with more than 10 Kt of yield have
a larger range of blast and burn than radiation effects. Damage
to people and objects from an atomic bomb depends on the size
of the explosion and distance from ground zero. It is virtually
impossible to determine whether victims succumb to blast, burn,
or radiation effects, since most victims suffer from all...and
many are simply vaporized. Effects also depend on whether the
bomb is detonated at ground level, which spews enormous amounts
of soil into the air and increases radioactive fallout, or in
the air, which increases the effect of blast and heat.
The major effects of an atomic bomb: BLAST: A 10
Kt bomb will create a crate between 1/4 and 1/2 mile wide and
several hundred feet deep. Wind velocity will be between 250 and
500 mph at the hypocenter, and over 60 mph even 2 miles away.Most
blast deaths and injuries result from the collapse of buildings,
from people being blown into objects at high speed, and from objects
being blown into people. Unreinforced buildings several miles
away may be destroyed or seriously damaged. The blast will be
so loud and intense and the pressures so great that people will
suffer ruptured eardrums with consequent deafness, and ruptured
lungs, many miles away. HEAT: The temperature at the center of
the blast will be approximately 1 million degrees C, approximately
that of the sun; even if the explosion is in the air, ground temperature
beneath it will be about 7000 degrees C. People 2.5 miles or more
away from the epicenter will suffer horrendous burns; wood will
be charred black 2 miles away. The heat will be sufficient to
evaporate metal, melt glass, and ignite clothing miles away from
the epicenter. At Hiroshima 8 sq. mi. of area was reduced to ashes
by a resulting firestorm. LIGHT: The intensity of emitted light
will be so great that people and animals will suffer retinal burns
up to 20 to 25 miles away, with at least temporary blindness for
hours to days, and possible permanent blindness. RADIATION: Short-term
and long-term effects will depend on the composition of the bomb
and the weather, as mentioned in Scenario #1.
ELECTROMAGNETIC PULSE:
This phenomenon will incapacitate radio, television, cellular
telephone, and cable transmissions for undetermined distances,
making communication in the entire region and possible entire
state unavailable, as well as permanently disabling appliances.
The Hiroshima bomb killed approximate 115,000 people
immediately or within a few days of its detonation. Tens of thousands
more were injured, a great many seriously. Among initial survivors
of a terrorist blast would be tens of thousands with extensive
third-degree burns. In all of the L.A. metropolitan area there
are 82 hospital burn beds; in all of California, 203; in the entire
U.S., about 5,000. Tens of thousands of survivors would suffer
crushing injuries, fractures, penetrating lacerations with heavy
bleeding, and acute radiation injury.
There are about 90 acute care hospitals in Los
Angeles County. Many would be destroyed or rendered non-functional
by the blast. Hospitals and doctors offices tend to be located
centrally in urban areas, so doctors would be killed or seriously
injured at rates greater than those of the general population.
There will be no help available from outside the devastated area,
not only because of fearfully high levels of radiation, and firestorms,
but also because there will be no electricity, communication,
shelter, or intact bridges or roads. Badly injured victims will
probably die in agony, without even the possibility of receiving
relief from pain. Those so-called survivors will probably envy
the dead. Apparently uninjured survivors miles from the explosion,
including police, government officials, fire personnel, gas station
attendants, store owners, bank and hospital employees -- almost
everyone -- will be thinking first of themselves and their loved
ones, how they can survive, and where they can flee to. Roads
out of the city will be jammed. Communities throughout the region,
such as Santa Barbara, will be inundated with those in panicked
flight, and hospitals in those regions will be deluged with people
who are either injured or think that they are. The medical system
in general, and emergency medicine in particular, will be completely
incapable of responding in any effective or meaningful way to
a terrorist nuclear bomb explosion. Medical preparation for such
an event may make us feel better, but only if we delude ourselves.
The only plausible strategy of preparation is the utmost effort
at prevention.
*Dr. Steve Daniels
is an emergency room physician in Santa Barbara, chairman of the
Santa Barbara chapter of the Physicians for Social Responsibility,
and a speaker in the Nuclear Age Peace Foundation's Speakers Bureau.
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