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        Foreword
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The importance of preparing and planning for a catastrophic incident the size and scope of a nuclear detonation cannot be overemphasized.123 The range of issues to be faced, including the physical, medical, psychological, legal, ethical, and economic consequences is daunting, but addressable. The Scarce Resources for a Nuclear Detonation Project builds on the groundwork and extraordinary efforts of many experts within4 and outside government.12 The approach to a nuclear threat involves prevention by control of nuclear material, detection, interdiction, render-safe, response, recovery, and resilience.

The magnitude of destruction possible from state-sponsored devices during the Cold War led to a sense of futility for civilian preparation. Since the Civil Defense planning era 50 to 60 years ago, there was little formal planning for nuclear detonation response until the events of September 11, 2001, and their aftermath. The scale of destruction of a terrorist nuclear attack pales in comparison to the apocalyptic visions of a nuclear exchange between national superpowers. Thoughtful planning is not futile and can substantially mitigate health consequences of a nuclear attack.

This issue of Disaster Medicine and Public Health Preparedness represents an effort by subject-matter experts from government, academia, and the private sector to do the following:

  • 1. Describe the physical environment and the casualty situation after a 10-kiloton nuclear detonation56

  • 2. Discuss the imbalance between resources and demand that produce the scarce-resources setting67

  • 3. Present supporting information and background material on acute radiation syndrome and medical care issues to help facilitate an effective response5

  • 4. Address the ethical, legal, psychological, and systemic challenges and the importance of both lifesaving and palliative/comfort care178910

  • 5. Provide measures that the overall medical system can take to prepare and respond to the scarce-resources setting, including a sample playbook for state and local planners to consider using711

  • 6. Define an approach (based on the new model of resource and time-based triage12) to medical care and triage in the extreme scarce resources environment that would follow in the initial 4 days after a detonation

  • 7. Provide practical guidance and a tool for use by planners and responders in triage victims. Although we recognize that it may have negative aspects especially because self/buddy-help and resilience are keys to the most effective societal response, the term victim is used throughout this issue as consistent with the terminology in the Planning Guidance for a Nuclear Detonation.4Casualty is used for people who are physically injured, but many more people will be affected and “victim” applies to all of those affected.13

There are no perfect solutions to these issues, but we hope that these manuscripts will stimulate thoughtful discussion and debate and additional research and development efforts.

We are grateful to the authors, reviewers, subject matter experts, editors, and other individuals who participated in this project. Although this group focused on a nuclear detonation and its unique aspects, many of the findings and recommendations are applicable to an all-hazards preparedness approach for catastrophic disasters and the resultant scarce-resources setting.23 The planning, preparing, and exercising processes to enhance response capabilities and resilience are never ending as new technologies, diagnostics, medical countermeasures, resource-sharing models, and the medical and physical sciences produce new knowledge and tools. This project is an important step toward addressing mass casualty challenges and we look forward to the dialogue, discussion, debate, collaboration, and progress that this effort will engender.

Author Disclosures: The author reports no conflicts of interest.

Acknowledgment: The authors acknowledge the contribution of Alicia Livinski, biomedical librarian, National Institutes of Health Library for assistance with the preparation of the foreword.

REFERENCES

1.The Next Challenge in Healthcare Preparedness. Catastrophic Health Events.Baltimore, MD: Center for Biosecurity of the University of Pittsburgh Medical Center; 2009.
2.Agency for Healthcare Research and Quality. Mass Medical Care With Scarce Resources: A Community Planning Guide.AHRQ Publication No. 07-0001. http://www.ahrq.gov/research/mce. Published February 2007. Accessed February 7, 2011.
3.Agency for Healthcare Research and Quality. Medical Care With Scarce Resources: The Essentials.AHRQ Publication No. 09-0016. http://www.ahrq.gov/prep/mmcessentials. Published September 2009. Accessed February 7, 2011.
4.Planning Guidance for Response to a Nuclear Detonation.2nd ed. Washington, DC: Homeland Security Council, Interagency Policy Coordination Subcommittee for Preparedness and Response to Radiological and Nuclear Threats; 2010. http://hps.org/hsc/documents/Planning_Guidance_for_Response_to_a_Nuclear_Detonation-2nd_Edition_FINAL.pdf. Accessed February 7, 2011.
5.DiCarlo, AL, Maher, C, Hick, JL.Radiation injury after a nuclear detonation: medical consequences and the need for scarce resources allocation. Disaster Med Public Health Prep. 2011;5(Suppl 1)S32S44.
6.Knebel, AR, Coleman, CN, Cliffer, KD.Allocation of scarce resources after a nuclear detonation: setting the context. Disaster Med Public Health Prep. 2011;5(Suppl 1)S20S31.
7.Hick, JL, Weinstock, DM, Coleman, CN.Health care system planning for and response to a nuclear detonation. Disaster Med Public Health Prep. 2011;5(Suppl 1)S73S88.
8.Caro, JJ, DeRenzo, EG, Coleman, CN.Resource allocation after a nuclear detonation incident: unaltered standards of ethical decision making. Disaster Med Public Health Prep. 2011;5(Suppl 1)S46S53.
9.Dodgen, D, Norwood, AE, Becker, SM.Social, psychological and behavioral responses to a nuclear detonation in a US city: implications for health care planning and delivery. Disaster Med Public Health Prep. 2011;5(Suppl 1)S54S64.
10.Sherman, SE.Legal considerations in a nuclear detonation. Disaster Med Public Health Prep. 2011;5(Suppl 1)S65S72.
11.Murrain-Hill, P, Coleman, CN, Hick, JL.Medical response to a nuclear detonation: creating a playbook for state and local planners and responders. Disaster Med Public Health Prep. 2011;5(Suppl 1)S89S97.
12.Casagrande, R, Wills, N, Kramer, E.Using the model of resource and time-based triage (MORTT) to guide scarce resource allocation in the aftermath of a nuclear detonation. Disaster Med Public Health Prep. 2011;5(Suppl 1)S98S110.
13.Coleman, CN, Weinstock, DM, Casagrande, R.Triage and treatment tools for use in a scarce resources-crisis standards of care setting after a nuclear detonation. Disaster Med Public Health Prep. 2011;5(Suppl 1)S111S121.