Correspondence

Nuclear terrorism: clues for emergency medicine of specific injuries

To the Editor,

The first matter that requires addressing is whether a tactical Nuclear device is a significant probability or simply a nightmare scenario without much substance.

The concern was probably first voiced by a physicist on the Manhattan project, Ted Turner, to the writer John McPhee in a vivid book, The Curve of Binding Energy [1], as Dr Turner took Mr McPhee to various locations in the United States where potential theft of nuclear materials could be imagined. Boureston and Mahaffey [2], in an elegant essay in Strategic Insights, elegantly laid out the fact that al-Qaeda aimed to top what they had done on 9/11 and that the most straightforward way of doing this was with a nuclear device. Volume IV of “Unmasking Terror” by the Jamestown Foundation, as edited by McGregor [3], noted on page 13 that al Zawahiri called off a subway terrorist attack in the United States because it was not an adequate follow-up to September 11, 2001. Although many described how easy it would be to make a simple gun-type nuclear device, perhaps the most detailed description is that by Coster-Mullen, self- published but widely available, who diligently uncovered the secrets of the gun-type device exploded over Hiroshima [4]. Simply put, a steel tube is sealed at one end with a hardball- sized ball of weapons-grade (85% or higher) U-235, while a pestle-like piece of the same amount of U-235 is lodged at the other end, with high explosive and a detonator. The detonator sets off the high explosive, sending the pestle-like piece of U-235 down the tube at great speed where it encompasses and compresses the U-235 hardball leading to critical then supercritical mass and subsequent nuclear detonation. DOE workers have been known to call such devices “garage bombs” as they can literally be made in a garage with the right equipment. Obtaining weapons-grade U-235 is beyond the scope of this article, but multiple attempts by terrorist groups have been tried in Russia, and the issue comes down to poor young soldiers and men with lots of money to spend. For a good consistent view of the dangers of such terrorist proliferation, the reader is referred to the National Threat Initiative, available on the internet, run

by Sam Nunn with an impressive board of directors. The author asked one very senior TV executive whether, if a group of physicists could be rounded up, it would possibly make a show a network was interested in. “No” was the answer, “we thought about it one day in New York and decided we’d all be dead.” Actually the opposite is true. An atomic bomb leaves a lethal zone in the center and a huge “doughnut” of citizens around that area who have traumatic injuries, thermal burns, radiation burns, radiation bone marrow effect that is not immediately obvious, and a huge group of worried well. Configuring emergency department (ED) triage is key as the ED is likely to be crowded, and help from Northern Command in the way of medical stations set up quickly will be a benefit, as well as hospitals in nearby states where patients can be taken.

A group from the Big Bang Team, paid by the Department of Defense to configure a possible attack, broke the ranks of secrecy and published in California Magazine a piece in their September 2005 issue, pages 1 to 7, called “Nuclear Fallout: Berkeley Team Thinks Beyond the Unthinkable.” Along with potential political ramifications, they gave a fairly good accounting of the damage of a 10-kiloton bomb that exploded in the heart of Moscow, reducing a good part of the city to rubble, killing several hundred thousands, and leaving a nation wary that some other superpower had set off the bomb. The actual problem of fallout, which lingers for 3 to 5 days and is absolutely lethal, and requires survivors to stay with food and water in their basements after an explosion, was elegantly portrayed in a piece missed by many by Professors WJ Perry, AB Carter, and MM May, in an OP ED in the New York Times in June of 2007, called “The Day After,” which then also went into the Washington Quarterly. Fallout threatened thousand of lives, was worst the day after the bomb had gone off, although fallout starts within minutes of the explosion. Hiroshima was particularly unlucky because it rained, and with the rain came down multiple isotopes including cesium daughter products with penetrating x-rays destined to destroy the lungs of those who breathed the air. Eventually, the Japanese realized that a huge doughnut of people had survived with minor burns and minor trauma but who received enough radiation to raise their long-term chances of cancer, while others died of radiation poisoning over the ensuing weeks.

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There are no physical signs that permit the physician to declare with certainty what dose if any a person received. The bomb’s heat (10 million degrees Celsius at the center), caused furniture and clothes to catch fire as far as a mile and a half away. Citizens had flash burns at 4 km from the center of the explosion. Many citizens simply had all their clothes burned off by the thermal heat, and handling the myriad of thermal burn victims may be less a matter of diagnosis and more a matter of supplies of adequate burn doctors and facilities. Radiation burns are very tricky to distinguish, and radiation oncologists are the specialists who know them best. They often look like sunburn at first, then slowly over a matter of a few weeks begin to show signs of protein leak, Skin breakdown, often without turning into third-degree burns. The sunburn radiation effect doesn’t start until 7-10 days after exposure. Knowledge from the clinic and from stories from Russia and South America help the radiation medicine physician. In South America, there have been incidents of thieves breaking into radiation centers and stealing isotopes only to eventually come to the hospital with significant burns. Bluntly put, anyone with a “sunburn” needs to be watched.

As for symptoms, nausea and possible vomiting were decided at the most recent annual meeting of radiation oncologists in Boston as the best signs of radiation exposure. The sooner the nausea after the blast, the higher the dose likely received. Diarrhea and neurologic signs suggest very significant whole-body dose and less likelihood of survival. The national strategic stockpile has bone marrow stimulating agent (G-CSF) and triple antibiotics to treat such patients because their sensitive bone marrow will be the first to go and their blood counts will dwindle down. Assessing radiation poisoning is no simple matter [5]. An excellent no-cost CD paid for by the Radiological Society of North America, and the brainchild of a radiobiologist, Mike Robbins, a professor at Wake Forest Medical School, can be obtained by writing Dr Robbins at mrobbins@wfubmc. edu. He goes the extra mile in an edited CD called Training the Trainers and describes blood studies that can be done including serial blood counts and karotyping for specific lymphocyte patterns including the formation of “dicentricts,” which are small pieces of DNA that form circles. Our national group is frankly split on these more subtle studies, clearly of great utility, but as for availability during a mass disaster, we might revert to the simplistic method of diagnosis (nausea and vomiting) of giving an aminoglyco- side, a third-generation broad-spectrum antibiotic granulo- cyte colony stimulating factor (G-CSF), and vancomycin, if there are breaks in the skin. It is not a bad idea to have a radiation oncologist and medical oncologist in the treatment team as one knows all about radiation and the other knows all about fevers of unknown origin in patients with a damaged bone marrow. It may also be helpful to try to find out how close to the blast were the individuals and when they came up for air, as crude assessments can be made of their potential radiation absorption [5].

In sum, unlike biologic and Chemical agents, radiation does not give many clinical clues and yet radiation dose may be the key to helping patients at the time of a blast and later through the years as scientists try to calculate their absorbed dose and the long-term carcinogenic/leukemo- genic risk. At this point, watching for symptoms of nausea and how soon after the blast the nausea started is a simple but realistic way of grossly assessing radiation dose. If there is time, serial blood counts and karotyping will be helpful. At this stage, the American Society of Therapeutic Radiology Oncology appears to be leaning toward immediate treatment of those who present with nausea and vomiting. For a more detailed picture, Dr Robbins’ free CD gives a better in depth sense of the problem. The common danger will be patients a week or two into treatment for thermal burns whose white counts start to drop. Burn patients with a weak marrow fare poorly.

A text by MJ Roy titled “Physicians Guide to terrorist attacks” may also prove useful [6].

Thomas E. Goffman MD

Cancer Intelligence and Research PC (C-INR)

Virginia Beach, VA 23455, USA E-mail address: [email protected]

doi:10.1016/j.ajem.2009.03.004

References

1. McPhee J. The curve of binding energy. New York: Farrar, Straus & Giroux; 1973.
2. Bourenston J, Mahaffey C. Al-Qaeda and mass casualty terrorism: assessing the threat. Strategic Insights 2003;2(10):1-4.
3. McGregor A. Unmasking terror IV. Washington (DC): Jamestown Foundation; 2008.
4. Coster-Mullen J. Atom bombs. Coster-Mullen; 2008.
5. Goffman TE. Nuclear disasters: current plans and future directions for oncologists. Am J Disaster Med 2008;3(6):317-20 [Also see Goffman TE. The Current state of affairs for disaster planning for a nuclear terrorist event, Am J Disaster Med 2009;4(1):59-64].
6. Roy MJ, editor. Physicians guide to terrorist attack. New Jersey: Humana Press; 2004.

Toxic chemical effects that might present in the ED

To the Editor,

Under what may now be considered a somewhat obscure provision, the United States passed a bill on October 17, 1986, called the Emergency Planning and Community Right to Know. Two events had occurred that sparked this legislation. First, there had been the release of a very toxic chemical, methyl isocyanate, from an American plant in Bhopal, India, in 1984. It would require a truly effete intellectual to not suggest to the reader a glimpse into the