|Fig. 1: Temporary shelter provided for individuals forced to evacuate due to wildfires. (Source: Wikimedia Commons)|
There are many potential sources of nuclear emergencies, including both accidents at nuclear power plants and detonation of nuclear weapons. Developing effective public health strategies to prepare the public and to respond to a nuclear emergency is critical to limit casualties following a nuclear event. With this goal in mind, a response to a nuclear emergency must include shelter and evacuation plans, medical management, triage, dosimetry, and communication with the public and between agencies.  The following will first provide some examples to demonstrate the scale of different nuclear events and then outline some challenges in responding to nuclear emergencies and strategies to address them.
In an effort to prepare for national emergencies, the United States has developed 15 national planning scenarios, one of which is the detonation of a 10 kT improvised nuclear device.  A detonation of this scale would produce a severe damage zone with a radius of 0.5 miles in which people are very unlikely to survive, a moderate damage zone with a radius of 1 mile, and a light damage zone with a radius of 3 miles.  Areas beyond the light damage zone also have the potential to be exposed to radioactive fallout, and should also be monitored following the nuclear event.  Such an event would lead to mass casualties, but an effective public health response could save many lives and limit longterm medical effects.
Communicating the need to shelter in place and wait for guidance on evacuation should occur both in preparation for a potential nuclear detonation and as soon as possible following a nuclear disaster. [2,3] Ensuring that victims shelter in place while they wait for further instruction on evacuation would greatly reduce the number of casualties resulting from a nuclear detonation. [2,3] To address this need, FEMA developed pre-scripted messages for both preparedness and as responses to a nuclear incident. 
Following a nuclear emergency, life saving medical interventions must be quickly implemented. In particular, resources must be allocated to ensure that methods for detection of radiation exposure and treatment are available. Providing medical assistance to potential victims following a nuclear emergency can be difficult if infrastructure damage limits access in any way.  As patients enter the medical system, sharing resources between different hospitals and cities and moving patients to locations with better knowledge in the treatment of radiation sickness will likely be necessary.  Some work has already been done to ensure patients have access to needed care. For example, the Radiation Injury Treatment Network (RITN), which is a network of cancer centers trained in dealing with severe cases, was established to provide care for patients with severe radiation exposures. 
One challenge in the application of medical interventions following a nuclear disaster is to identify the patients who should receive treatment first if there is a shortage of resources or personnel, which would likely be the case following a nuclear detonation.  Treating the sickest patients first may not be the best option because it may be impossible to save them, and given the lack of resources, careful consideration of resource utilization is necessary. [1,2] In fact, it has been suggested that focusing the response on the moderate damage zone would save 20,000-30,000 additional lives in the case of a 10 kT detonation in a city the size of Washington, DC.  Furthermore, advances in biodosimetry may also allow for patients to be sorted into groups based on how much radiation they were exposed to so that resources can be effectively allocated to specific groups. 
Like many natural disasters, a nuclear disaster has the potential to force the evacuation of many people. Developing plans to provide the shelter and resources needed by these individuals is an important part of any nuclear emergency plan. Resources and support that have effectively aided displaced populations following other natural disasters (fires, hurricanes, etc.) provide practical evidence for how to best manage this situation and should be carefully considered in any plan for aiding displaced individuals.  Fig. 1 shows an example of temporary shelter provided to individuals forced to evacuate due to wildfires.
This has focused on a subset of the many elements necessary to mount a complete public health response to a nuclear emergency. Various groups have attempted to summarize aspects of nuclear emergency response to provide resources that could be used to respond to such an event. This includes the nuclear incidence medical enterprise, the national concept of operations (CONOPS) for a response to a nuclear detonation, the Radiation Triage, Transport, and Treatment (RTR) System, and the Radiation Emergency Medical Management (REMM), which may be extremely helpful guidelines in the event of a nuclear emergency. [1,2]
© Winston Becker. The author warrants that the work is the author's own and that Stanford University provided no input other than typesetting and referencing guidelines. The author grants permission to copy, distribute and display this work in unaltered form, with attribution to the author, for noncommercial purposes only. All other rights, including commercial rights, are reserved to the author.
 J. F. Koerner, "Preparedness is More Than a Plan: Medical Considerations for Radiation Response," Health Phys. 114, 128 (2018).
 C. N. Coleman et al., "Public Health and Medical Preparedness for a Nuclear Detonation: The Nuclear Incident Medical Enterprise," Health Phys. 108, 149 (2015).
 L. M. Wein, Y. Choi, and S. Denuit, "Analyzing Evacuation Versus Shelter-in-Place Strategies After a Terrorist Nuclear Detonation," Risk Anal. 30, 1315 (2010).
 J. M. Sullivan et al., "Assessment of Biodosimetry Methods for a Mass-casualty Radiological Incident: Medical Response and Management Considerations," Health Phys. 105, 540 (2013).
 A. Salame-Alfie and A. Ansari, "Assessment of National Efforts in Emergency Preparedness for Nuclear Terrorism: Is there a Need for Realignment to Close Remaining Gaps," Health Phys. 114, 261 (2018).