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.