Allocation of scarce resources after a nuclear detonation: setting the context.

The purpose of this article is to set the context for this special issue of Disaster Medicine and Public Health Preparedness on the allocation of scarce resources in an improvised nuclear device incident. A nuclear detonation occurs when a sufficient amount of fissile material is brought suddenly together to reach critical mass and cause an explosion. Although the chance of a nuclear detonation is thought to be small, the consequences are potentially catastrophic, so planning for an effective medical response is necessary, albeit complex. A substantial nuclear detonation will result in physical effects and a great number of casualties that will require an organized medical response to save lives. With this type of incident, the demand for resources to treat casualties will far exceed what is available. To meet the goal of providing medical care (including symptomatic/palliative care) with fairness as the underlying ethical principle, planning for allocation of scarce resources among all involved sectors needs to be integrated and practiced. With thoughtful and realistic planning, the medical response in the chaotic environment may be made more effective and efficient for both victims and medical responders.

The "RTR" medical response system for nuclear and radiological mass-casualty incidents: a functional TRiage-TReatment-TRansport medical response model.

Developing a mass-casualty medical response to the detonation of an improvised nuclear device (IND) or large radiological dispersal device (RDD) requires unique advanced planning due to the potential magnitude of the event, lack of warning, and radiation hazards. In order for medical care and resources to be collocated and matched to the requirements, a [US] Federal interagency medical response-planning group has developed a conceptual approach for responding to such nuclear and radiological incidents. The "RTR" system (comprising Radiation-specific TRiage, TReatment, TRansport sites) is designed to support medical care following a nuclear incident. Its purpose is to characterize, organize, and efficiently deploy appropriate materiel and personnel assets as close as physically possible to various categories of victims while preserving the safety of responders. The RTR system is not a medical triage system for individual patients. After an incident is characterized and safe perimeters are established, RTR sites should be determined in real-time that are based on the extent of destruction, environmental factors, residual radiation, available infrastructure, and transportation routes. Such RTR sites are divided into three types depending on their physical/situational relationship to the incident. The RTR1 sites are near the epicenter with residual radiation and include victims with blast injuries and other major traumatic injuries including radiation exposure; RTR2 sites are situated in relationship to the plume with varying amounts of residual radiation present, with most victims being ambulatory; and RTR3 sites are collection and transport sites with minimal or no radiation present or exposure risk and a victim population with a potential variety of injuries or radiation exposures. Medical Care sites are predetermined sites at which definitive medical care is given to those in immediate need of care. They include local/regional hospitals, medical centers, other sites such as nursing homes and outpatient clinics, nationwide expert medical centers (such as cancer or burn centers), and possible alternate care facilities such as Federal Medical Stations. Assembly Centers for displaced or evacuating persons are predetermined and spontaneous sites safely outside of the perimeter of the incident, for use by those who need no immediate medical attention or only minor assistance. Decontamination requirements are important considerations for all RTR, Medical Care, and Assembly Center sites and transport vehicles. The US Department of Health and Human Services is working on a long-term project to generate a database for potential medical care sites and assembly centers so that information is immediately available should an incident occur.