Forgotten Casualties: Hospitals in the Aftermath of a Nuclear Detonation


By Mark L. Maiello, Ph.D. and Jenna Mandel-Ricci, MPA, MPH*, New York City Department of Health & Mental Hygiene *Greater New York Hospital Association

Computer modeling and associated work by the US Department of Energy over the past decade has led to a greater understanding by the emergency planning community about the impacts of small, 10 kiloton fission weapons detonated in urban environments. This work concluded that the relatively small size of the weapon – chosen as a size conceivably built by terrorists - and the manner in which modern cities are constructed, would leave many survivors needing rescue. The false idea that everyone would be killed and that a response was impossible or unnecessary has been put aside in favor of planning for some sort of population evacuation and mass triage of casualties. Many may still consider this an impossible or near-impossible task, but the fact remains that in New York City, 1 million casualties are an eventuality with over 7 million left alive and in survival mode. Similar to a natural disaster such as a superstorm, they will need the basic necessities of life: food, water, medical assistance, shelter and information about what will happen next. A significant response will be needed.

Make no mistake, the result of such a detonation will kill nearly everyone and level most if not all buildings within 0.5 miles of ground zero. Further out to 1 mile, a zone of “moderate-level” damage will prevail with clogged streets from destroyed automobiles, parts of collapsed buildings and other inoperable infrastructure. Here, many people will survive, and it is here that planners have been told that rescue is still possible. From 1 to 3 miles, a light damage zone extends outwards until no damage is observed. Here, debris and other factors causing human injury that are so common in the moderate damage zone such as broken building window glass begin to gradually become less frequent. There is one other lethal component that we must consider no matter the damage zone: radiation from radioactive fallout. Assuming the weapon is ground deployed and performs efficiently, a mushroom cloud could develop, sucking up the melted components of nearby buildings, asphalt, soil, and whatever else is present at ground zero. Anything there can be vaporized at the extreme temperatures of the fireball (at tens of millions of degrees F). That material will eventually fall back to earth under the pull of gravity as particles, much of it visible and all of it very radioactive. Initial exposure rates caused by fallout can be so high that less than one hour of exposure under the correct circumstances can sicken or eventually kill people. There may be only 10 minutes post detonation before it begins to rain down in a potentially wide area preferentially determined by the direction of prevailing winds at altitude. And, although fallout radioactivity may decay relatively rapidly with time (a factor of 10 for every 7-fold increase in time measured from the moment of detonation), it may be many days before the exposure rate is low enough to consider venturing outside for limited periods of time without fear of short term or long-term effects depending on location.

Lost, perhaps even forgotten in the planning efforts so far, have been hospitals. Those rescued after fallout has sufficiently decayed need a place to be treated.

The bleak backdrop to this worse day ever is made darker by the infrastructure damage that will hinder survival and rescue. Electrical power is likely to be eliminated throughout the city and perhaps beyond. Streets in the moderate damage zone and even parts of the light damage area are likely to be impassable due to rubble. Automobiles are likely to have been wrecked in numerous accidents brought on by the flash blindness of drivers exposed to the intense light of the fire ball (under the correct circumstances this can extend for 15 miles from ground zero), with the subsequent car wrecks making ground travel within and into the city by anyone, including responders, very problematic. Without power, even relatively undamaged underground transport will cease. The same may be said of access to water – it may or may not be available depending on the use of pumps. The post-detonation environment is literally a living hell.

Lost, perhaps even forgotten in the planning efforts so far, have been hospitals. Those rescued after fallout has sufficiently decayed need a place to be treated. That may not be local hospitals. Like other buildings in the high damage zone, hospital structures located there will be destroyed. The chances for operability increase in the outer regions of the moderate, light, and distant no damage zones. But what do these hospitals do to maintain their operations and serve those impacted by the detonation who are seeking care? How do they respond to the lack of resources and information?

In late 2018 and into the summer of 2019, colleagues at the NYC Department of Health & Mental Hygiene and the Greater New York Hospital Association developed a workgroup structure to explore these very questions. Emergency Management and clinical professionals from about 25 hospitals located in and around New York City were brought together over several half day sessions to discuss what they would prioritize 1 day, 2 days and 3 days post detonation. We asked them to consider their response for three zone locations starting at the moderate damage zone and working to the distant no damage zone. They were also educated on the basics of radiation fallout so that they could account for it in their responses. The critical emergency management functions of the Joint Commission on Hospital Accreditation were used to frame the discussions.

New York City-based hospital emergency managers and their associates fell back on the one event that most resembled the nuclear weapon effects that were described to them: Superstorm Sandy (October 2012). Due to the flooding and the subsequent loss of power, some hospitals in New York City had to take extreme measures to protect their staff and patients. And from an information and communication standpoint, many drew upon their experiences of 9/11. With those incidents in mind, hospital emergency managers came to these conclusions:

  • It was acknowledged that the situation was an existential threat. Medicine without computers, electrical power for monitors, life support equipment and electronic records is 19th century medicine at best. Water, if cut off, turns hospitals off.
  • Fallout could be partially handled by moving patients into the interior of buildings away from outer walls and windows and from the top floors where penetrating radiation from fallout accumulating on roof surfaces can be dangerous to human health.
  • Damage to buildings, lack of, or diminishing power and water (expected in varying degrees in moderate damage and even light damage zones) results in one overriding conclusion: hospitals should be evacuated within 72 hours.
  • In response to this, hospitals in the no damage zones around the city sought to prepare themselves to receive evacuated patients, with a focus on preservation of resources and coordination with other response assets.
(...) because Acute Radiation Syndrome (ARS) is so rare and not taught in medical schools, an ARS Toolkit to assist with recognition and triage of radiation sickness would be tremendously helpful

Responses specific to the Joint Commission critical areas fell into three categories:

  • Guidance: Medical personnel need guidance for technical areas unique to the post-nuclear detonation environment. For example, because Acute Radiation Syndrome (ARS) is so rare and not taught in medical schools, an ARS Toolkit to assist with recognition and triage of radiation sickness would be tremendously helpful, as would a just-in-time training module on ARS. Similarly desirable, would be guidance on the use of radiation monitoring devices such as Geiger Counters usually found in the radiation safety departments of hospitals, in order for hospitals to set up real-time facility monitoring for exposure and contamination in the hours after a detonation. Such monitoring would guide internal movement of staff and patients.
  • Situational Awareness/Communications: Emergency managers wanted situational awareness but were unsure that the traditional means to acquire it such as cable TV or broadcast radio would be operational. They called for a preset schedule for reception of outside information and for broadcasting hospital status and needs to a “lead government agency” using 800 MHz radios. Information about the direction and intensity of fallout would be needed to implement effective shelter-in-place procedures. Details about the detonation were not only important to the response but also necessary for messaging, and to inform operational decision-making.
  • Staffing/Supplies: Although streets were described as impassable, it is assumed that the injured and uninjured would make their way to hospital doors to seek care, shelter and safety. Crowd control, potential introduction of weapons into the hospital environment and the credentialing of doctors and other medical personnel who may find a means to volunteer were some of the security concerns expressed. Emergency managers prioritized the need for fully developing a plan to bring federal medical assets such as Disaster Medical Assistance Teams to the affected area and to educate hospital personnel about such plans. Alternative supply pathways, including waterways, for medical resource resupply including potable water – at least for receiving hospitals and perhaps even for hospitals that can continue operations in the light damage zone – are in need of development.

These are but a few of the requests that hospital emergency response personnel made during our workshops. One however stands out: Hospitals in the moderate damage zone and inner portions of the light damage zone cut off from power and water will be immediately thrown into a crisis care situation, where patient needs immediately overwhelms available resources. Crisis care situations can require life and death triage of patients based on available resources and any expectations concerning the resolution of the resource poor circumstances. It is critical in these situations to have a fair, equitable and just approach to allocating limited life-saving resources described as a “Crisis Standards of Care” to apply to victims that have reasonable chances of survival. Crisis standards of care carry legal as well as ethical ramifications that have not lent themselves to easy discussion or resolution even after years of deliberation. Nor shall it be so here. But in the post-nuclear detonation environment, with resources cut off and with little or no chance of replenishment for days, their use will be required.

As these hospitals gradually face the reality of their dwindling resources, their leadership will seek information critical to the survival of their patients and staff: radiation levels, the feasibility of transport to receiving hospitals, and the aforementioned resource replenishment. They will want to know if and how their patients can be moved to operational facilities. Planners will have to consider these communication and transportation nightmares that are the inevitable consequences of the unprecedented destructive power of nuclear weapons.

There can be no illusions when it comes to a nuclear detonation. Even a small device will bring utter catastrophe to a minimum of 3 miles around ground zero and fallout and its potentially lethal radiation to far larger areas many miles away. If 7 million New Yorkers survive, hospitals will be the islands of hope many will seek. The question remains: Can we plan “well enough” for the short- and long-term post-nuclear survival of hospitals and those they serve?

The authors would like to acknowledge Timothy Styles, MD, MPH, Medical Director of the Bureau of Healthcare and Community Readiness at the NYC Department of Health & Mental Hygiene and CDC Career Epidemiology Field Officer with the Center for Prevention and Response, for his invaluable insight and assistance with the planning and running of the workshops that made these findings possible.

Mark L. Maiello, Ph.D. is Radiological Projects Planning Manager in the Office of Emergency Preparedness & Response at the NYC Department of Health and Mental Hygiene and is co-chair of the NYC Radiological Response and Recovery Committee. In addition, Mark helped to create the NYC Radiological Advisory Committee of outside experts who can assist with a citywide radiological response. After graduate school at NYU, Mark worked at the US Department of Energy’s Environmental Measurements Lab in NYC. He was a radiation safety officer for 17 years with Wyeth Research and later Pfizer Pharmaceuticals Inc. at facilities in Pearl River, NY and Groton, CT. Mark has previously published in the field of radiological preparedness including a review of US nuclear emergency response assets and the security of Cs-137 blood irradiators. He co-edited the book Radioactive Air Sampling Methods published in 2011 by CRC Press. Mark currently serves as the book review editor for the Journal of Nuclear Materials Management.

Jenna Mandel-Ricci serves as Vice President, Regulatory and Professional Affairs at the Greater New York Hospital Association which is a trade association representing more than 160 member hospitals and health systems in New York, New Jersey, Connecticut, and Rhode Island. Jenna supports member hospitals in two principle areas – emergency preparedness, and development and implementation of internal employee wellness programs. Under her leadership, GNYHA has led many initiatives to improve coordination between hospital and government response agencies. Jenna has supported members through a number of emergency events including Ebola, Zika, measles, power outages, severe weather, and most recently the spring 2020 COVID-19 patient surge, during which time she served as GNYHA’s Incident Commander. Before joining GNYHA, Jenna spent the previous decade in various positions including at the New York City Department of Health and Mental Hygiene.