Since the earliest discoveries related to nuclear energy by scientists such as Pierre and Marie Curie and Wilhelm Roentgen, there have been biomedical implications associated with radiological exposure. That first detonation of a prototype nuclear device in the New Mexico desert, and the effects of the atomic bombings on Hiroshima and Nagasaki vividly demonstrated the fearsome destructive forces unleashed and subsequent health effects of a nuclear detonation. These effects are well documented, as are the ones of the unfortunate intentional human experimentation utilizing radionuclides and external sources of radiation.

During the Cold War, elaborate national plans were drafted and implemented, along with an active Civil Defense program to engage citizens in emergency preparedness and community recovery in the aftermath of a strategic nuclear strike against the U.S. Similar plans and programs were initiated in nation-states that had acquired nuclear capabilities, such as Russia, as the primary adversary during this period. The concept of “Mutually Assured Destruction” (M.A.D.) may have kept the balance of terror at an even keel; however, during this tense period of history, there were frequent miscalculations, failures and other incidents that may have triggered nuclear confrontation and subsequent global thermonuclear warfare.
Despite the fact that there has been downsizing of nuclear arsenals, the grave possibility of strategic thermonuclear warfare still remains and the threat of nuclear – radiological terrorism utilizing an improvised nuclear device (IND) or large radiological dispersal device (RDD) looms on the horizon. The increasing likelihood of rogue nations acquiring nuclear weapons, and the use of INDs and RDDs by terrorist factions have created pressing concerns and needs for a workable medical response system to address these specific threats.

Data continues to suggest that health care systems are still woefully underprepared to handle victims of an IND or large RDD attack on a civilian population. Addressing such attacks involves unique advanced planning due to the potential magnitude of the event, lack of warning, and inherent radiological hazards. Even in a small yield IND attack, catastrophic damage to any existing local infrastructure, including hospitals and health care could be expected, hindering meaningful response to mass casualties. At once, the challenges of responding to nuclear-radiological events are complex and daunting.

In the U.S., a conceptual and interagency approach to medical consequence management has been developed, which can be considered as a model for planning and response to other global stakeholders: The “RTR” system (Radiation –specific TRiage, TReatment, TRansport sites) is designed to support medical care following a nuclear or radiological event. Its purpose is to characterize, organize and efficiently deploy appropriate materiel and personnel assets as close as physically possible to various victim categories and provide for the safety of responders. It addresses medical, public health and human service needs specific to nuclear-radiological events.

The RTR model was planned and conceived with analysis of the US Department of Homeland Security’s (DHS) National Planning Scenarios, ie. Improvised Nuclear Device (IND, Scenario #1) which utilizes a potential 10-kiloton (kt) detonation in an urban environment, and Radiological Dispersal Device (RDD, Scenario # 11), a Cesium-137 (CS 137-cesium chloride) improvised explosive RDD detonation. Compliance and consistency with the roles and responsibilities of the US Department of Health and Human Services (HHS) by Homeland Security Presidential Directives (HSPDs) # 18 and # 21,and the National Response Framework (NRF), Emergency Support Function # 8 (ESF # 8-Public Health and Medical Services), are essential requisites for the overall RTR functional model.

The development of the RTR model engaged the evaluation of various military/civilian medical response plans and casualty loads and injury/illness matrices were provided by the Interagency Modeling and Atmospheric Assessment Center (DHS), the National Atmospheric Release Advisory Center, and the Defense Threat Reduction Agency (DTRA). While not designated as an individualized triage system, the RTR would be able to establish sites after the event characterization and perimeters are established. RTR sites need to be determined and established in real-time and must take into account event severity, damage assessments, available infrastructure, evacuation and transportation routes, radiological hazards, and environmental factors, eg. topography, precipitation, wind speed and direction, and non-radiological hazards.

RTR sites are divided into three categories:
• RTR1- Designated near the epicenter with residual radiation and would provide medical response and support for major traumatic injuries, including blast injury and radiation exposure.
• RTR2- Established in relationship to plume modeling, varying amounts of residual radiation and serving mostly ambulatory victims.
• RTR3- Serve as casualty collection points (CCPs) and transport venues with minimal or absent radiological hazards or exposure risks and an assorted matrix of injuries and /or radiation exposures.

Medical Care (MC) sites are predetermined venues at which definitive medical care is administered to those that have been triaged as requiring immediate medical care. The obvious components of a health care system, such as local and regional hospitals, Veterans Administration hospitals, nursing homes, outpatient clinics, and specialty centers such as burn, shock-trauma, oncology and related facilities would all be involved in catastrophic medical care and expected to function in an austere operational environment, and must be prepared to decontaminate patient influxes. Alternative Care Sites (ACS), such as pre-determined Federal Medical Stations (FMS). These could be school gymnasiums, convention centers or other venues designated to expand medical surge capacity in communities. In addition, adequate medical countermeasures, such as colony-stimulating factor cytokines for bone marrow suppression due to Acute Radiation Syndrome (ACS) and decorporation agents must be made available based upon medical triage decision-making and health physics evaluations. Proper personal protective countermeasures, ie., time, distance and shielding ,and personal protective equipment (PPE) must be applied by all health care providers and pre-hospital/emergency response personnel.
Protective Action Guidelines (PAGs) have been developed for nuclear power accidents, and have been made applicable to intentional nuclear–radiological events utilizing evidence-based development and interagency consensus. PAGs are to be utilized to provide guidance on time limitations and “allowable exposures” during operational duties in various conditions involving radioactivity.

The spectrum of medical consequences associated with IND or RDD detonation include temporary and permanent blindness, such as flash blindness, retinal burns, (IND), blast injuries, burn trauma, crush syndrome due to structural collapse and victim entrapment, and acute and latent/chronic health effects observed with radiation exposure, including the possibility of increased cancer risk. The behavioral health impacts will be great and require both immediate mental health crisis interventions and long term mental health services for survivors, including responders. It is important to denote that traumatic injuries and concomitant radiation exposure contribute to higher mortality rates, than the sum of individual injuries. In addition, blast and thermal injuries may occur without radiological exposures and radiological exposures may occur without traumatic injuries. Ethical dilemmas will be present, during the allocation of scarce resources. Assembly Centers for displaced populations and evacuees are also a component of the RTR scheme.
While realistic planning for the medical and public health consequences of an IND or RDD detonation are obvious priorities given our current threat assessments, improvements and proactive measures and methodologies to detect, deter and interdict weapons-grade nuclear material, thwart acquisition of nuclear weapons by rogue regimes, and tighter controls on other radioactive sources will do much to avert that fateful day.

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Frank G. Rando possesses over 30 years of real world experience as a public safety professional,clinician, educator ,emergency and crisis manager ,author and consultant in the areas of tactical ,disaster and operational medicine, weapons and tactics, law enforcement /criminal investigations ,counterterrorism, hazardous materials management and emergency response ,toxicology, environmental safety and health,and health care and public health emergency management .