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Responding to Nuclear Terrorism: What EMS Providers Need to Know

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The idea of responding to an act of nuclear terrorism can be daunting. Some may assume everyone will be dead, so why bother? Others may picture devastation so widespread they won’t be able to respond. Finally, people in rural areas often believe that since a nuclear detonation (nucdet) would likely only occur in an urban area, they have no need for preparations.

All of these assumptions are, to varying degrees, incorrect. During the Cold War, American fears centered on the prospect of nuclear war and the promised Armageddon that would result. As that threat ebbed following the dissolution of the Soviet Union, civil defense preparations and resources that had been established to protect Americans from the effects of a nucdet were reduced to near-dormancy. However, concerns about a nucdet have made a recent resurgence on two fronts: conventional nuclear weapons (CNWs) and nuclear terrorism (i.e., the use of an improvised nuclear device, or IND). 

Following the collapse of the Soviet Union, most Americans didn’t think much about the prospect of a nucdet; however, recent tension with North Korea and the false nuclear weapon alert in Hawaii have caused a reemergence of fears of use of a CNW. More importantly, terrorism experts have never discounted the possibility—no matter how remote—of an IND attack. 

The IND Threat Landscape

The U.S. Department of Homeland Security has developed 16 catastrophic planning scenarios. National Planning Scenario #1 involves a terrorist acquiring nuclear material and fashioning it into a 10-kiloton IND that is employed in an urban area, which has the explosive yield approximately 4,500 times greater than the Oklahoma City bomb. Although considered a remote possibility because of safeguards in place in our cities and ports, an IND event could cause hundreds of thousands of deaths and injuries. 

However, potential devastation on this scale does not mean EMS personnel should throw their hands in the air and write off planning as futile. Rather, responders should understand the predicted impacts and be able to separate the mythology of nuclear consequences from the reality.

Effects of Nuclear Weapons 

Nuclear weapons affect living beings, infrastructure, and the environment. A nucdet will produce a massive and instantaneous release of pressure, heat, and radiation—each creating devastating impact of its own.
A nucdet produces a blast wave that emanates out in all directions from the point of detonation (ground zero). Peak overpressure—the pressure beyond atmospheric pressure caused by a shock wave—can reach 200 pounds per square inch and be accompanied by hurricane-force winds. Such pressures are enough to destroy structures and kill people and animals through internal blunt trauma. Winds can pick people up and throw them against hard objects. Winds can also make shrapnel and projectiles out of glass, wood, and other objects.

In addition to the pressure wave, a nucdet produces an instantaneous fireball that can reach 2,000ºC. This fireball will incinerate virtually anything it contacts. Along with the instant fireball, the nuclear reaction that creates the explosion will release so-called prompt radiation, or a massive amount of radioactive subparticles that travel at the speed of light and can pass through the human body and penetrate deep into most modern structures. Prompt radiation disrupts the tissues of the body, producing burns, tissue damage, and changes to cellular structures and DNA. These insults cause both immediate and long-term effects. 

The blast wave disrupts soil and can pulverize concrete and other building materials, creating a fine dust that gets lofted into the atmosphere and mixed with radioactive particles. Eventually this radioactive dust returns to earth as radioactive fallout, which can mix with water supplies and cover people, animals, agricultural products, and structures. Fallout poses a danger to humans and animals because it can be incorporated into the body or accumulate on the skin and hair, where it will continue to irradiate until washed off or excreted.

Finally, a nucdet will have an impact on critical infrastructure in several ways. First, the blast overpressure will destroy structures. Second, fires will be caused by excessively high temperatures and disruptions to electric and gas service lines (although ground zero and immediately adjacent areas will not have fires because the fuels will have been destroyed and blown away). Third, destruction of urban structures will generate huge piles of debris. 

The loss of electricity, communications, and water infrastructure will have secondary impacts on society’s ability to deal with the response to and recovery from the nucdet. For example, fire departments will be hampered in extinguishing fires because water mains will be disrupted in many areas. Additionally, the loss of potable water will have an enormous effect on human and animal habitation, especially since natural water supplies may be affected by fallout. Debris on roadways and loss of bridges (and potentially tunnels) will impede the ability of emergency responders to get around and interrupt or hinder the supply chain for critical resources to reach affected areas. 

Finally, a nucdet will produce an electromagnetic pulse (EMP), the extent of which will depend on the height of burst, or detonation altitude. Although not insignificant, EMP effects can often be overstated. An IND will produce so-called “source region” EMP, with effects less far-reaching than popularly conceived.

Unshielded telecommunications and computing equipment that have “long lines” (i.e., tethered to long power or communications lines) will be affected, but handheld radios and cell phones likely will continue to operate (although base station radios and cellular towers may be destroyed or experience interruptions). This means portable radios could be used in point-to-point communications and potentially work if base stations are properly shielded. While cell phones will not work unless they can reach a working tower, smartphones should continue to provide computing capability and GPS (which could prove critical in the absence of street signs and landmarks).

Damage Zones

Contrary to the popular conception that a nucdet will produce total devastation, the extent of damage in a given area will depend on its distance from ground zero and power of the weapon (or the yield). Federal government IND planning documents address three concentric rings of varying levels of damage: moving outward from ground zero, the severe, moderate, and light damage zones, respectively.1 Figure 1 shows the three damage zones for a notional nucdet at 16th and K Streets in Washington, D.C. It is important to remember in viewing this figure that the lines of demarcation between the three zones are not distinct. For this reason they are depicted with fuzzy borders. Appropriate actions for emergency responders vary by damage zone.

Severe damage zone—Extending from ground zero outward approximately half a mile, the severe damage zone (SDZ) would closely resemble the popular conception of a nuclear holocaust. Virtually everything in the SDZ would be destroyed by the overpressure wave and accompanying fireball. There would be no survivors within the SDZ. Anyone who miraculously survived the pressure wave and 2,000ºC temperatures would receive such an overwhelming whole-body dose of gamma radiation that they would probably die within hours. The number of casualties in the SDZ would depend on the number of people there at the time of detonation, but estimates of fatalities for large metropolitan areas are in the hundreds of thousands. For example, in the Washington, D.C., nucdet scenario, FEMA estimates 240,000 people would die.2 There would be few fires within the SDZ because the destruction of buildings and infrastructure would be so complete as to deny fires the fuel to burn. Given that there would be no people or property to save and because of the extreme levels of radiation near ground zero, emergency personnel would never need to enter the SDZ.

Moderate damage zone—About a half-mile from ground zero, the landscape would begin to shift from total devastation to one that contained both survivors and damaged structures. This is the moderate damage zone (MDZ). The degree and number of injuries would largely depend upon the distance of survivors from ground zero. People who were closer would sustain more injuries and more severe injuries—from blast, burn, and radiation. Structures closer to the SDZ would be more severely damaged.

The MDZ is where emergency services agencies will be able to save the most lives; however, conditions will be austere. Roadways will likely be blocked by large piles of debris. Navigation will be difficult because street signs and landmarks will have been lost. Critical infrastructure such as communications equipment, water for fire suppression, and gas and electric lines will likely have been disrupted. There will be many fatalities in the MDZ, but there will also be numerous survivors—some entrapped, some not. Survivors will require rescue, decontamination, medical treatment, evacuation to fallout shelters and medical facilities, and other care (e.g., food).

Injuries within the MDZ will range from minor to life-threatening and include burns, barotrauma, blunt and penetrating multisystem trauma from people being thrown against objects and vice versa, and heart attacks, as well as the normal spectrum of medical conditions seen in any population during noncatastrophic conditions. Additionally, many people will suffer from temporary (or longer-term) flash blindness due to the intense brilliant light associated with a nucdet. Responders should focus their lifesaving efforts on the MDZ, as this is where the salvageable patients with the greatest need for care will be found.

Light damage zone—Outside the MDZ, effects on people, structures, and infrastructure will be more limited. Buildings may suffer light damage such as broken glass, cracks in walls, and door frames being forced out of alignment; however, most structures should survive intact. People may suffer minor, non-life-threatening injuries. Most injuries will come from flying glass and debris. Additionally, the stress and shock of a nuclear attack may precipitate heart attacks, and flash blindness among drivers will likely cause vehicle crashes with accompanying injuries.

Emergency responders will likely see a surge in call volume in the LDZ, both for emergencies and because panicked people call 9-1-1 not knowing what else to do. Public safety answering points may need to implement more rigorous triaging of calls in order to direct resources to incidents where there is an actual opportunity (and need) to save lives. In all likelihood, however, there will be a much greater need for emergency services in the MDZ than the LDZ.

Treatment Principles

The great overpressures and wind associated with a nucdet will produce blunt and penetrating trauma, but most patients in the MDZ will likely suffer from combined injuries (i.e., trauma and radiation injuries). As radiation passes through the body, it kills blood cells, disrupts DNA, and causes burns. People who receive large doses of radiation over short periods of time often develop acute radiation syndrome (ARS), which can result in death within hours (for extremely high doses of radiation) or over a more prolonged period. Survivors who receive cytokine therapy within 24 hours of irradiation may be saved, especially if other life threats (i.e., trauma) are addressed.3

Therefore, the care philosophy following a nucdet should be to treat immediate life threats first. Patients will present with trauma, medical, and radiological insults, but the standard life threats are going to kill patients before any radiological condition will. EMS personnel should treat conditions that will prevent a physician from dealing with the effects of irradiation; however, they will need to triage patients in a manner that takes into account the likelihood of survival if the patient has been irradiated.

Standard EMS triage approaches (e.g., START) will not properly identify salvageable patients as they do not account for the effects of irradiation and ARS. Properly triaging patients requires factoring in the likelihood of survival as a function of the total body dose of radiation received. Figure 2 depicts a triage protocol that reflects the greater mortality associated with higher doses of radiation. The key feature of this system is that patient expectancy is driven by the time of onset of nausea and vomiting.

Patient Decon and PPE

All survivors (whether patients or not) should undergo decontamination. The longer radioactive particles sit on skin, hair, or clothing, the more irradiated that person will be. Removing those radioactive particles can be achieved by doffing contaminated clothing and showering (with soap, preferably) and shampooing.
If water is not available, decontamination should be performed using a cloth or soft brush. Further, if the hair cannot be shampooed, it should be cut off as close to the scalp as possible to prevent continued exposure to radioactive particles. Finally, skin folds should be cleaned to prevent contaminated water or fallout particles from accumulating. If EMS personnel can do nothing else, decontamination in this manner will save lives!

The most important consideration for emergency responders following a nucdet is to resist the urge to respond to calls. It is vitally important that people “get inside, stay inside, and stay tuned” to shelter themselves from radioactive fallout. This includes first responders, because dead first responders don’t save lives!

Vehicles provide no protection. Shelter in a building until directions are received about when it is safe to leave and where the dangerous fallout zone is (it will change with time). In general, responders should plan on staying put for at least 12 hours.

During decontamination and treatment, personnel should wear personal protective equipment including a full-facepiece air-purifying respirator with a P100 or high-efficiency particulate air (HEPA) filter—N95 masks do not provide sufficient respiratory protection. This level of PPE does not provide protection against ionizing radiation, only against external and internal contamination. Personnel should change PPE and shower as possible, but certainly before ingesting food or water. All personnel should refrain from smoking.

Healthcare System Impacts

EMS personnel must understand how a nucdet would affect the healthcare system in order to set expectations for patient management and how the system would interact with the larger healthcare system.

Close-in impacts—Close in to ground zero, the healthcare system would suffer four forms of adverse impact. First, any surviving healthcare facility in the MDZ or LDZ would probably be affected by the loss of critical infrastructure such as electricity, air conditioning, water supply, and external data communications. Second, a tidal wave of walking wounded would inundate such facilities with demands for treatment. Third, medical supplies would be quickly depleted and unable to be replenished (perhaps for weeks or months). Finally, medical personnel would be in short supply.

One could expect medical facilities in the MDZ, LDZ, and perhaps as far away as 20 miles from ground zero to be operating under crisis conditions, including a modified form of patient triage and significantly reduced treatment regimens.

Remote impacts—Hospitals farther from ground zero would be able to deliver healthcare that is closer to normal. However, patients would need to be distributed throughout the U.S. healthcare system. In some cases this will tax the remote healthcare systems (see Figure 3).

Burn bed availability—Nowhere will this be more evident than in the treatment of burn patients. American College of Surgeons data from 2011 shows there were 1,918 beds in 128 “verified” burn centers across the United States.4 FEMA estimates as many as 320,000 casualties following a nucdet in Washington D.C.5 Using blast injury patterns from terrorist bombings as a proxy, we can assume that 9% of patients presenting to hospitals would be burned.6

This means there would likely be (at a minimum) nearly 30,000 burn patients to be treated—more than 15 times the total number of burn beds in the United States. Furthermore, at any given point in time, most burn beds across the nation are filled.7 

Ventilator needs—A similar situation would exist for patients needing ventilators, as the demand would exceed supply.

The healthcare system would have to mobilize on a national level to respond to a nucdet. Medical personnel and resources would be shifted closer to ground zero. The federal government would mobilize military and civilian resources such as Disaster Medical Assistance Teams (DMATs), and EMS agencies would be called upon to provide mutual aid to affected areas as well as serve as the backbone for moving patients to more remote facilities. A massive mental healthcare response would be needed.

Although an act of nuclear terrorism would be catastrophic, it would not be apocalyptic. EMS would be front and center in assisting. However, EMS won’t be able to respond effectively if administrators and personnel do not plan for such an event.


1. National Security Staff Interagency Policy Coordination Subcommittee for Preparedness & Response to Radiological and Nuclear Threats. Planning Guidance for Response to a Nuclear Detonation, 2nd ed.;

2. Cuartas JB, Polley R. Region III National Capital Region Improvised Nuclear Device Response Plan, Information Analysis Briefing, May 13, 2014, p. 28.

3. Two cytokines are FDA-approved for treatment of ARS: Neupogen and Neulasta. These drugs are not for use by prehospital personnel, but EMS providers should understand that their efficacy depends on initiation of therapy in a timely manner. For more information see

4. Data compiled by the American College of Surgeons and abstracted by the author.

5. Op. cit., Cuartas, Polley, p. 28.

6. Stricklin D; Applied Research Associates, Inc. Unpublished data via private communications with the author, 2015.

7. Poovey B. Hospitals are Shutting Down Burn Centers. Washington Post, 2007 Aug 7;

Erik Gaull, NRP, CEM, CPP, MEP,  is a Master Firefighter/Paramedic III with the Cabin John Park (Md.) Volunteer Fire Department and an officer in the Reserve Division with the D.C. Metropolitan Police Department. He is a member of EMS World’s editorial advisory board. 

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