Health care system planning for and response to a nuclear detonation

The hallmark of a successful response to a nuclear detonation will be the resilience of the community, region, and nation. An incident of this magnitude will rapidly become a national incident; however, the initial critical steps to reduce lives lost, save the lives that can be saved with the resources available, and understand and apply resources available to a complex and dynamic situation will be the responsibility of the local and regional responders and planners. Expectations of the public health and health care systems will be met to the extent possible by coordination, cooperation, and an effort to produce as consistent a response as possible for the victims. Responders will face extraordinarily stressful situations, and their own physical and psychological health is of great importance to optimizing the response. This article illustrates through vignettes and supporting text how the incident may unfold for the various components of the health and medical systems and provides additional context for the discipline-related actions outlined in the state and local planners’ playbook

Surge Capacity Logistics

Successful management of a pandemic or disaster requires implementation of preexisting plans to minimize loss of life and maintain control. Managing the expected surges in intensive care capacity requires strategic planning from a systems perspective and includes focused intensive care abilities and requirements as well as all individuals and organizations involved in hospital and regional planning. The suggestions in this article are important for all involved in a large-scale disaster or pandemic, including front-line clinicians, hospital administrators, and public health or government officials. Specifically, this article focuses on surge logistics—those elements that provide the capability to deliver mass critical care.The Surge Capacity topic panel developed 23 key questions focused on the following domains: systems issues; equipment, supplies, and pharmaceuticals; staffing; and informatics. Literature searches were conducted to identify studies upon which evidence-based recommendations could be made.This article presents 22 suggestions pertaining to surge capacity mass critical care, including requirements for equipment, supplies, and pharmaceuticals; staff preparation and organization; methods of mitigating overwhelming patient loads; the role of deployable critical care services; and the use of transportation assets to support the surge 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 \u3e2 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

Theodicy and End-of-Life Care

Acknowledgments The section on Islamic perspective is contributed by information provided by Imranali Panjwani, Tutor in Theology & Religious Studies, King's College London.Peer reviewedPublisher PD

Clinical review: Allocating ventilators during large-scale disasters – problems, planning, and process

Catastrophic disasters, particularly a pandemic of influenza, may force difficult allocation decisions when demand for mechanical ventilation greatly exceeds available resources. These situations demand integrated incident management responses on the part of the health care facility and community, including resource management, provider liability protection, community education and information, and health care facility decision-making processes designed to allocate resources as justly as possible. If inadequate resources are available despite optimal incident management, a process that is evidence-based and as objective as possible should be used to allocate ventilators. The process and decision tools should be codified pre-event by the local and regional healthcare entities, public health agencies, and the community. A proposed decision tool uses predictive scoring systems, disease-specific prognostic factors, response to current mechanical ventilation, duration of current and expected therapies, and underlying disease states to guide decisions about which patients will receive mechanical ventilation. Although research in the specifics of the decision tools remains nascent, critical care physicians are urged to work with their health care facilities, public health agencies, and communities to ensure that a just and clinically sound systematic approach to these situations is in place prior to their occurrence