Health care system planning for and response to a nuclear detonation

Overlapping Science in Radiation and Sulfur Mustard Exposures of Skin and Lung: Consideration of Models, Mechanisms, Organ Systems, and Medical Countermeasures: Overlapping science in radiation and sulfur mustard injuries to lung and skin

PURPOSE

To summarize presentations and discussions from the 2022 trans-agency workshop titled "Overlapping science in radiation and sulfur mustard (SM) exposures of skin and lung: Consideration of models, mechanisms, organ systems, and medical countermeasures."

METHODS

Summary on topics includes: (1) an overview of the radiation and chemical countermeasure development programs and missions; (2) regulatory and industry perspectives for drugs and devices; 3) pathophysiology of skin and lung following radiation or SM exposure; 4) mechanisms of action/targets, biomarkers of injury; and 5) animal models that simulate anticipated clinical responses.

RESULTS

There are striking similarities between injuries caused by radiation and SM exposures. Primary outcomes from both types of exposure include acute injuries, while late complications comprise chronic inflammation, oxidative stress, and vascular dysfunction, which can culminate in fibrosis in both skin and lung organ systems. This workshop brought together academic and industrial researchers, medical practitioners, US Government program officials, and regulators to discuss lung-, and skin- specific animal models and biomarkers, novel pathways of injury and recovery, and paths to licensure for products to address radiation or SM injuries.

CONCLUSIONS

Regular communications between the radiological and chemical injury research communities can enhance the state-of-the-science, provide a unique perspective on novel therapeutic strategies, and improve overall US Government emergency preparedness.

Nuclear Disaster Preparedness Level of Medical Responders in Pakistan

Pakistan is a country with nuclear capability in a region sharing borders with 2 other nuclear powers-that is, India to the east and China to the northeast. This geographic positioning makes the area a nuclear flash point. It is therefore imperative to have commensurate health-care facilities to meet any eventualities. Although Pakistan is trying to improve medical facilities for the people, health-care facilities are already overwhelmed with patients because of the large population of the country. The current study was conducted to evaluate the level of awareness and preparedness of medical responders for nuclear and radiological disasters in public hospitals in the major cities of Pakistan. Methods: A detailed questionnaire covering all aspects of the study was designed and discussed with the people most concerned, including health-care workers in the field of medicine, nuclear sciences, and disaster management in Pakistan. It was adopted on the basis of early studies on the subject, with necessary modifications to fulfill the requirements at Pakistan's level. Semistructured interviews were also conducted with key personnel of different response agencies in Pakistan. Results: Of 880 surveys, 554 were completed and collected from medical providers in different hospitals across the country. The respondents included doctors, nurses, and medical assistants from emergency and nonemergency departments. They are aware of the catastrophic consequences of nuclear disaster and are willing to respond to these kinds of disasters voluntarily, but they are not satisfied with their level of preparedness and awareness regarding nuclear and radiological disasters. Conclusion: Although medical responders have good educational backgrounds and knowledge in their specific fields and are quite active and energetic in their response to conventional injuries and natural disasters, they feel a dire need to enhance their level of knowledge about and preparedness for unconventional disasters and injuries such as those caused by nuclear or radiological events.

Radiation Injury Treatment Network Medical and Nursing Workforce Radiation: Knowledge and Attitude Assessment

Objectives:

The Radiation Injury Treatment Network (RITN) is prepared to respond to a national disaster resulting in mass casualties with marrow toxic injuries. How effective existing RITN workforce education and training is, or whether health-care providers (HCPs) at these centers possess the knowledge and skills to care for patients following a radiation emergency is unclear. HCP knowledge regarding the medical effects and medical management of radiation-exposed patients, along with clinical competence and willingness to care for patients following a radiation emergency was assessed.

Methods:

An online survey was conducted to assess level of knowledge regarding the medical effects of radiation, medical/nursing management of patients, self-perception of clinical competence, and willingness to respond to radiation emergencies and nuclear events.

Results:

Attendance at previous radiation emergency management courses and overall knowledge scores were low for all respondents. The majority indicated they were willing to respond to a radiation event, but few believed they were clinically competent to do so.

Conclusions:

Despite willingness to respond, HCPs at RITN centers may not possess adequate knowledge of medical management of radiation patients, and appropriate response actions during a radiation emergency. RITN should increase the awareness of the importance of radiation education and training.

Developing a Model for Hospitals' Emergency Department Preparedness in Radiation and Nuclear Incidents and Nuclear Terrorism in Iran

Objective

To develop a national model for hospitals' Emergency Department (ED) preparedness when facing radiation and nuclear incidents as well as nuclear terrorism in Iran.

Methods

This analytical study was carried out in 2019 via Delphi technique in two rounds and prioritization using a pairwise questionnaire. Using classic Delphi technique and pairwise comparison, the components were given to 32 specialists in emergency medicine, nuclear medicine, medical physics, nuclear physics, radiobiology and radiation protection, health in disaster and emergency, and passive defense. Finally, the national model was developed by holding two focus group sessions.

Results

The results from the two rounds of Delphi technique showed that 31 factors of preparedness were classified into three main classes, namely staff, stuff, and structure (system). Only three factors were excluded and the rest were agreed upon by the specialists. Given the weight of each class, it was found that staff preparedness and stuff preparedness had the highest and lowest priorities, respectively.

Conclusion

Comprehensive preparedness requires enhancing and promoting cultural, social, economic, and political levels. Indeed, all preparedness levels should be promoted in alignment with each other. Hence, governments should align their policies to manage such incidents.

National Assessment of Nursing Schools and Nurse Educators Readiness for Radiation Emergencies and Nuclear Events

Nurses will play a crucial role in responding to a public health emergency resulting from nuclear war or other large-scale release of radiation into the environment and in supporting the National Health Security Strategy. Schools of nursing are ultimately responsible for developing a competent nursing workforce prepared to assess a population’s public health emergency needs and respond to these low-frequency but high-impact events. This responsibility includes the provision of specific content and training regarding how to respond and care for patients and communities in the event of a nuclear or radiation emergency. To date, however, there has been a lack of empirical evidence focusing specifically on nursing schools’ capacity to prepare nurses for radiation emergencies and nuclear events, as well as perception of risk. This study employed a cross-sectional survey administered to a nationwide sample of nursing school administrators and faculty to assess content, faculty expertise, planning, and perception of risk related to radiation emergencies and nuclear events.

The nursing profession: a critical component of the growing need for a nuclear global health workforce

BACKGROUND

Instability in the global geopolitical climate and the continuing spread of nuclear weapons and increase in their lethality has made the exchange of nuclear weapons or a terrorist attack upon a nuclear power plant a serious issue that demands appropriate planning for response. In response to this threat, the development of a nuclear global health workforce under the technical expertise of the International Atomic Energy Agency and the World Health Organization Radiation Emergency Medical Preparedness and Assistance Network has been proposed.

MAIN BODY OF THE ABSTRACT

As the largest component of the global healthcare workforce, nurses will play a critical role in both the leadership and health care effectiveness of a response to any public health emergency of international concern (PHEIC) resulting from the unprecedented numbers of trauma, thermal burn, and radiation affected patients that will require extensive involvement of the nursing professional community.

SHORT CONCLUSION

Lives can and will be saved if nurses are present. The clinical care of radiation contaminated patients (e.g. radiation burns, fluid management, infection control), thermal burn patients, and other health system response activities such as community screening for radiation exposure, triage, decontamination, administration of medical countermeasures and the provision of supportive emotional and mental health care will be overwhelmingly nurse intensive.

rBPI21 (Opebacan) Promotes Rapid Trilineage Hematopoietic Recovery in a Murine Model of High-Dose Total Body Irradiation

The complexity of providing adequate care after radiation exposure has drawn increasing attention. While most therapeutic development has focused on improving survival at lethal radiation doses, acute hematopoietic syndrome (AHS) occurs at substantially lower exposures. Thus, it is likely that a large proportion of such a radiation-exposed population will manifest AHS of variable degree and that the medical and socioeconomic costs of AHS will accrue. Here, we examined the potential of rBPI21 (opebacan), used without supportive care, to accelerate hematopoietic recovery after radiation where expected survival was substantial (42-75%) at 30 days). rBPI21 administration was associated with accelerated recovery of hematopoietic precursors and normal marrow cellularity, with increases in megakaryocyte numbers particularly marked. This translated into attaining normal trilineage peripheral blood counts 2-3 weeks earlier than controls. Elevations of hematopoietic growth factors observed in plasma and the marrow microenvironment suggest the mechanism is likely multifactorial and not confined to known endotoxin-neutralizing and cytokine down-modulating activities of rBPI21 . These observations deserve further exploration in radiation models and other settings where inadequate hematopoiesis is a prominent feature. These experiments also model the potential of therapeutics to limit the allocation of scarce resources after catastrophic exposures as an endpoint independent of lethality mitigation. This article is protected by copyright. All rights reserved.

Disaster Planning: Financing a Burn Disaster, Where Do You Turn and What Are Your Options When Your Hospital Has Been Impacted by a Burn Disaster in the United States?

The cost associated with a single burn injured patient can be significant. The American healthcare system functions in part based on traditional market forces which include supply and demand. In addition, there are a variety of payer sources with disparate payment for the same services. Thus, when a group of patients with serious injuries needing complicated care are underinsured or uninsured, or lacks the ability to pay, the financial health of the organization providing the care can be undermined. When a medical disaster with significant numbers of burn injured patients occurs, the financial concerns can be compounded with this singular event. It is critical to be cognizant of the disaster-related financial resources available. Knowing where to turn and what may be available can help assure that the institution caring for this group of high cost patients does not simultaneously take on significant financial risk in the aftermath of the disaster. This article includes national (United States) financial data with respect to burn injury, and focuses on (United States) governmental financial resources during and after a disaster. This review includes identifying and discussing traditional financial support, as well as atypical but established programs where, during a disaster, health care institutions may be eligible for assistance to cover part or all of the associated costs.

Proposed "Exposure And Symptom Triage" (EAST) Tool to Assess Radiation Exposure After a Nuclear Detonation

ABSTRACTOne of the biggest medical challenges after the detonation of a nuclear device will be implementing a strategy to assess the severity of radiation exposure among survivors and to triage them appropriately. Those found to be at significant risk for radiation injury can be prioritized to receive potentially lifesaving myeloid cytokines and to be evacuated to other communities with intact health care infrastructure prior to the onset of severe complications of bone marrow suppression. Currently, the most efficient and accessible triage method is the use of sequential complete blood counts to assess lymphocyte depletion kinetics that correlate with estimated whole-body dose radiation exposure. However, even this simple test will likely not be available initially on the scale required to assess the at-risk population. Additional variables such as geographic location of exposure, sheltering, and signs and symptoms may be useful for initial sorting. An interdisciplinary working group composed of federal, state, and local public health experts proposes an Exposure And Symptom Triage (EAST) tool combining estimates of exposure from maps with clinical assessments and single lymphocyte counts if available. The proposed tool may help sort survivors efficiently at assembly centers near the damage and fallout zones and enable rapid prioritization for appropriate treatment and transport. (Disaster Med Public Health Preparedness. 2018; 12: 386-395).

Disaster Preparedness and Response for the Burn Mass Casualty Incident in the Twenty-first Century

The effective and efficient coordination of emergent patient care at the point of injury followed by the systematic resource-based triage of casualties are the most critical factors that influence patient outcomes after mass casualty incidents (MCIs). The effectiveness and appropriateness of implemented actions are largely determined by the extent and efficacy of the planning and preparation that occur before the MCI. The goal of this work was to define the essential efforts related to planning, preparation, and execution of acute and subacute medical care for disaster burn casualties. This type of MCI is frequently referred to as a burn MCI."

A Course on Terror Medicine: Content and Evaluations

Introduction

The development of medical school courses on medical responses for disaster victims has been deemed largely inadequate. To address this gap, a 2-week elective course on Terror Medicine (a field related to Disaster and Emergency Medicine) has been designed for fourth year students at Rutgers New Jersey Medical School in Newark, New Jersey (USA). This elective is part of an overall curricular plan to broaden exposure to topics related to Terror Medicine throughout the undergraduate medical education.

Rationale

A course on Terror Medicine necessarily includes key aspects of Disaster and Emergency Medicine, though the converse is not the case. Courses on Disaster Medicine may not address features distinctively associated with a terror attack. Thus, a terror-related focus not only assures attention to this important subject but to accidental or naturally occurring incidents as well.

Methods

The course, implemented in 2014, uses a variety of teaching modalities including lectures, videos, and tabletop and hands-on simulation exercises. The subject matter includes biological and chemical terrorism, disaster management, mechanisms of injury, and psychiatry. This report outlines the elective’s goals and objectives, describes the course syllabus, and presents outcomes based on student evaluations of the initial iterations of the elective offering.

Results

All students rated the course as “excellent” or “very good.” Evaluations included enthusiastic comments about the content, methods of instruction, and especially the value of the simulation exercises. Students also reported finding the course novel and engaging.

Conclusion

An elective course on Terror Medicine, as described, is shown to be feasible and successful. The student participants found the content relevant to their education and the manner of instruction effective. This course may serve as a model for other medical schools contemplating the expansion or inclusion of Terror Medicine-related topics in their curriculum.

ColeLA, NatalB, FoxA, CooperA, KennedyCA, ConnellND, SugalskiG, KulkarniM, FeravoloM, LambaS. A course on Terror Medicine: content and evaluations. Prehosp Disaster Med. 2016;31(1):98–101.

Developing a Nuclear Global Health Workforce Amid the Increasing Threat of a Nuclear Crisis

This study argues that any nuclear weapon exchange or major nuclear plant meltdown, in the categories of human systems failure and conflict-based crises, will immediately provoke an unprecedented public health emergency of international concern. Notwithstanding nuclear triage and management plans and technical monitoring standards within the International Atomic Energy Agency and the World Health Organization (WHO), the capacity to rapidly deploy a robust professional workforce with the internal coordination and collaboration capabilities required for large-scale nuclear crises is profoundly lacking. A similar dilemma, evident in the early stages of the Ebola epidemic, was eventually managed by using worldwide infectious disease experts from the Global Outbreak Alert and Response Network and multiple multidisciplinary WHO-supported foreign medical teams. This success has led the WHO to propose the development of a Global Health Workforce. A strategic format is proposed for nuclear preparedness and response that builds and expands on the current model for infectious disease outbreak currently under consideration. This study proposes the inclusion of a nuclear global health workforce under the technical expertise of the International Atomic Energy Agency and WHO's Radiation Emergency Medical Preparedness and Assistance Network leadership and supported by the International Health Regulations Treaty. Rationales are set forth for the development, structure, and function of a nuclear workforce based on health outcomes research that define the unique health, health systems, and public health challenges of a nuclear crisis. Recent research supports that life-saving opportunities are possible, but only if a rapidly deployed and robust multidisciplinary response component exists.

Disaster planning: the past, present, and future concepts and principles of managing a surge of burn injured patients for those involved in hospital facility planning and preparedness

The 9/11 attacks reframed the narrative regarding disaster medicine. Bypass strategies have been replaced with absorption strategies and are more specifically described as "surge capacity." In the succeeding years, a consensus has coalesced around stratifying the surge capacity into three distinct tiers: conventional, contingency, and crisis surge capacities. For the purpose of this work, these three distinct tiers were adapted specifically to burn surge for disaster planning activities at hospitals where burn centers are not located. A review was conducted involving published plans, other related academic works, and findings from actual disasters as well as modeling. The aim was to create burn-specific definitions for surge capacity for hospitals where a burn center is not located. The three-tier consensus description of surge capacity is delineated in their respective stratifications by what will hereinafter be referred to as the three "S's"; staff, space, and supplies (also referred to as supplies, pharmaceuticals, and equipment). This effort also included the creation of a checklist for nonburn center hospitals to assist in their development of a burn surge plan. Patients with serious burn injuries should always be moved to and managed at burn centers, but during a medical disaster with significant numbers of burn injured patients, there may be impediments to meeting this goal. It may be necessary for burn injured patients to remain for hours in an outlying hospital until being moved to a burn center. This work was aimed at aiding local and regional hospitals in developing an extemporizing measure until their burn injured patients can be moved to and managed at a burn center(s).

User-Managed Inventory: An Approach to Forward-Deployment of Urgently Needed Medical Countermeasures for Mass-Casualty and Terrorism Incidents

The user-managed inventory (UMI) is an emerging idea for enhancing the current distribution and maintenance system for emergency medical countermeasures (MCMs). It increases current capabilities for the dispensing and distribution of MCMs and enhances local/regional preparedness and resilience. In the UMI, critical MCMs, especially those in routine medical use (“dual utility”) and those that must be administered soon after an incident before outside supplies can arrive, are stored at multiple medical facilities (including medical supply or distribution networks) across the United States. The medical facilities store a sufficient cache to meet part of the surge needs but not so much that the resources expire before they would be used in the normal course of business. In an emergency, these extra supplies can be used locally to treat casualties, including evacuees from incidents in other localities. This system, which is at the interface of local/regional and federal response, provides response capacity before the arrival of supplies from the Strategic National Stockpile (SNS) and thus enhances the local/regional medical responders' ability to provide life-saving MCMs that otherwise would be delayed. The UMI can be more cost-effective than stockpiling by avoiding costs due to drug expiration, disposal of expired stockpiled supplies, and repurchase for replacement.

(Disaster Med Public Health Preparedness. 2012;6:408-414)

Using the Model of Resource and Time-Based Triage (MORTT) to Guide Scarce Resource Allocation in the Aftermath of a Nuclear Detonation

Conventional triage algorithms assume unlimited medical resource availability. After a nuclear detonation, medical resources are likely to be particularly limited, suggesting that conventional triage algorithms need to be rethought. To test various hypotheses related to the prioritization of victims in this setting, we developed the model of resource- and time-based triage (MORTT). This model uses information on time to death, probability of survival if treated and if untreated, and time to treat various types of traumatic injuries in an agent-based model in which the time of medical practitioners or materials can be limited. In this embodiment, MORTT focuses solely on triage for surgical procedures in the first 48 hours after a nuclear detonation. MORTT determines the impact on survival based on user-selected prioritization of victims by severity or type of injury. Using MORTT, we found that in poorly resourced settings, prioritizing victims with moderate life-threatening injuries over victims with severe life-threatening injuries saves more lives and reduces demand for intensive care, which is likely to outstrip local and national capacity. Furthermore, more lives would be saved if victims with combined injury (ie, trauma plus radiation >2 Gy) are prioritized after nonirradiated victims with similar trauma.

(Disaster Med Public Health Preparedness. 2011;5:S98-S110)

US screening of international travelers for radioactive contamination after the Japanese nuclear plant disaster in March 2011

On March 11, 2011, a magnitude 9.0 earthquake and subsequent tsunami damaged nuclear reactors at the Fukushima Daiichi complex in Japan, resulting in radionuclide release. In response, US officials augmented existing radiological screening at its ports of entry (POEs) to detect and decontaminate travelers contaminated with radioactive materials. During March 12 to 16, radiation screening protocols detected 3 travelers from Japan with external radioactive material contamination at 2 air POEs. Beginning March 23, federal officials collaborated with state and local public health and radiation control authorities to enhance screening and decontamination protocols at POEs. Approximately 543 000 (99%) travelers arriving directly from Japan at 25 US airports were screened for radiation contamination from March 17 to April 30, and no traveler was detected with contamination sufficient to require a large-scale public health response. The response highlighted synergistic collaboration across government levels and leveraged screening methods already in place at POEs, leading to rapid protocol implementation. Policy development, planning, training, and exercising response protocols and the establishment of federal authority to compel decontamination of travelers are needed for future radiological responses. Comparison of resource-intensive screening costs with the public health yield should guide policy decisions, given the historically low frequency of contaminated travelers arriving during radiological disasters.

Radiation disasters: role of the BMT team

Bone marrow transplant (BMT) teams do not generally consider themselves to be emergency responders. But the bone marrow is the most radiosensitive organ in the body, and early changes in peripheral blood counts remain the best indicator of major total-body radiation exposures. Following a mass casualty incident, such as that occasioned by a nuclear detonation, BMT teams should expect that they will be called upon for their expertise in managing severe myelosuppression. Numerous resources, including the Radiation Injury Treatment Network, are available to assist BMT teams in planning for such a role.

Gene expression-based detection of radiation exposure in mice after treatment with granulocyte colony-stimulating factor and lipopolysaccharide

In a large-scale nuclear incident, many thousands of people may be exposed to a wide range of radiation doses. Rapid biological dosimetry will be required on an individualized basis to estimate the exposures and to make treatment decisions. To ameliorate the adverse effects of exposure, victims may be treated with one or more cytokine growth factors, including granulocyte colony-stimulating factor (G-CSF), which has therapeutic efficacy for treating radiation-induced bone marrow ablation by stimulating granulopoiesis. The existence of infections and the administration of G-CSF each may confound the ability to achieve reliable dosimetry by gene expression analysis. In this study, C57BL/6 mice were used to determine the extent to which G-CSF and lipopolysaccharide (LPS, which simulates infection by gram-negative bacteria) alter the expression of genes that are either radiation-responsive or non-responsive, i.e., show potential for use as endogenous controls. Mice were acutely exposed to (60)Co γ rays at either 0 Gy or 6 Gy. Two hours later the animals were injected with either 0.1 mg/kg of G-CSF or 0.3 mg/kg of LPS. Expression levels of 96 different gene targets were evaluated in peripheral blood after an additional 4 or 24 h using real-time quantitative PCR. The results indicate that the expression levels of some genes are altered by LPS, but altered expression after G-CSF treatment was generally not observed. The expression levels of many genes therefore retain utility for biological dosimetry or as endogenous controls. These data suggest that PCR-based quantitative gene expression analyses may have utility in radiation biodosimetry in humans even in the presence of an infection or after treatment with G-CSF.

Social, psychological, and behavioral responses to a nuclear detonation in a US city: implications for health care planning and delivery

A nuclear detonation in a US city would have profound psychological, social, and behavioral effects. This article reviews the scientific literature on human responses to radiation incidents and disasters in general, and examines potential behavioral health care provider (BHCP) contributions in the hours and days after a nuclear detonation. In the area directly affected by the blast, the immediate overarching goal of BHCP interventions is the support of lifesaving activities and the prevention of additional casualties from fallout. These interventions include 6 broad categories: promoting appropriate protective actions, discouraging dangerous behaviors, managing patient/survivor flow to facilitate the best use of scarce resources, supporting first responders, assisting with triage, and delivering palliative care when appropriate. At more distant sites, BHCP should work with medical providers to support hospitalized survivors of the detonation. Recommendations are also made on BHCP interventions later in the response phase and during recovery.

Medical response to a nuclear detonation: creating a playbook for state and local planners and responders

For efficient and effective medical responses to mass casualty events, detailed advanced planning is required. For federal responders, this is an ongoing responsibility. The US Department of Health and Human Services (DHHS) prepares playbooks with formal, written plans that are reviewed, updated, and exercised regularly. Recognizing that state and local responders with fewer resources may be helped in creating their own event-specific response plans, subject matter experts from the range of sectors comprising the Scarce Resources for a Nuclear Detonation Project, provided for this first time a state and local planner's playbook template for responding to a nuclear detonation. The playbook elements are adapted from DHHS playbooks with appropriate modification for state and local planners. Individualization by venue is expected, reflecting specific assets, populations, geography, preferences, and expertise. This playbook template is designed to be a practical tool with sufficient background information and options for step-by-step individualized planning and response.

Radiation injury after a nuclear detonation: medical consequences and the need for scarce resources allocation

A 10-kiloton (kT) nuclear detonation within a US city could expose hundreds of thousands of people to radiation. The Scarce Resources for a Nuclear Detonation Project was undertaken to guide community planning and response in the aftermath of a nuclear detonation, when demand will greatly exceed available resources. This article reviews the pertinent literature on radiation injuries from human exposures and animal models to provide a foundation for the triage and management approaches outlined in this special issue. Whole-body doses >2 Gy can produce clinically significant acute radiation syndrome (ARS), which classically involves the hematologic, gastrointestinal, cutaneous, and cardiovascular/central nervous systems. The severity and presentation of ARS are affected by several factors, including radiation dose and dose rate, interindividual variability in radiation response, type of radiation (eg, gamma alone, gamma plus neutrons), partial-body shielding, and possibly age, sex, and certain preexisting medical conditions. The combination of radiation with trauma, burns, or both (ie, combined injury) confers a worse prognosis than the same dose of radiation alone. Supportive care measures, including fluid support, antibiotics, and possibly myeloid cytokines (eg, granulocyte colony-stimulating factor), can improve the prognosis for some irradiated casualties. Finally, expert guidance and surge capacity for casualties with ARS are available from the Radiation Emergency Medical Management Web site and the Radiation Injury Treatment Network.

Triage and treatment tools for use in a scarce resources-crisis standards of care setting after a nuclear detonation

Based on background information in this special issue of the journal, possible triage recommendations for the first 4 days following a nuclear detonation, when response resources will be limited, are provided. The series includes: modeling for physical infrastructure damage; severity and number of injuries; expected outcome of triage to immediate, delayed, or expectant management; resources required for treating injuries of varying severity; and how resource scarcity (particularly medical personnel) worsens outcome. Four key underlying considerations are: 1.) resource adequacy will vary greatly across the response areas by time and location; 2.) to achieve fairness in resource allocation, a common triage approach is important; 3.) at some times and locations, it will be necessary to change from "conventional" to "contingency" or "crisis" standards of medical care (with a resulting change in triage approach from treating the "sickest first" to treating those "most likely to survive" first); and 4.) clinical reassessment and repeat triage are critical, as resource scarcity worsens or improves. Changing triage order and conserving and allocating resources for both lifesaving and palliative care can maintain fairness, support symptomatic care, and save more lives. Included in this article are printable triage cards that reflect our recommendations. These are not formal guidelines. With new research, data, and discussion, these recommendations will undoubtedly evolve.

Resource allocation after a nuclear detonation incident: unaltered standards of ethical decision making

This article provides practical ethical guidance for clinicians making decisions after a nuclear detonation, in advance of the full establishment of a coordinated response. We argue that the utilitarian maxim of the greatest good for the greatest number, interpreted only as "the most lives saved," needs refinement. We take the philosophical position that utilitarian efficiency should be tempered by the principle of fairness in making decisions about providing lifesaving interventions and palliation. The most practical way to achieve these goals is to mirror the ethical precepts of routine clinical practice, in which 3 factors govern resource allocation: order of presentation, patient's medical need, and effectiveness of an intervention. Although these basic ethical standards do not change, priority is given in a crisis to those at highest need in whom interventions are expected to be effective. If available resources will not be effective in meeting the need, then it is unfair to expend them and they should be allocated to another patient with high need and greater expectation for survival if treated. As shortage becomes critical, thresholds for intervention become more stringent. Although the focus of providers will be on the victims of the event, the needs of patients already receiving care before the detonation also must be considered. Those not allocated intervention must still be provided as much appropriate comfort, assistance, relief of symptoms, and explanations as possible, given the available resources. Reassessment of patients' clinical status and priority for intervention also should be conducted with regularity.