Public Health Emergency Preparedness

Chapter 7. 1 KT and 10 KT Nuclear Device

This chapter describes the assumptions for the nuclear scenario (both 1 KT and 10 KT), including:

• The severity categories.
• The arrival pattern of casualties at the hospital(s).
• The length of stay by hospital unit (i.e., ED, ICU, and the floor).
• The path probability within the hospital(s) and the length of stay.
• The overall outcome probabilities (i.e., probability of discharge and probability of death).
• The assumed level of resource consumption per patient per day per hospital unit.

Footnotes in the text of a particular section refer to references at the end of the section. In the absence of specific references, parameter estimates were obtained from general references listed in the Hospital Module section.

7.1 Severity Categories

For the 1 KT and 10 KT scenarios, patients arrive at the hospital(s) in one of eleven conditions:

1. Burns (1)/moderate: Second-degree burns on hands and face.
2. Burns (2))/severe: Third-degree burns on hands and face (and first-degree over the rest of the body).
3. Trauma (1)/people who receive multiple lacerations from flying glass.
4. Trauma (2)/people who receive blunt trauma.
5. Trauma (3)/people in collapsed houses and other light buildings.
6. Trauma (4)/people in collapsed skyscrapers.
7. Radiation (1)/ mild: Nausea, vomiting, anorexia, fever, infections.
8. Radiation (2)/moderate: More severe mild symptoms, plus bleeding, fatigue, and weakness.
9. Radiation (3)/severe: More severe moderate symptoms, plus headache, prostration, dizziness, and disorientation.
10. Fallout (1)/mild: 1Gy equivalent dose for blood effects, no other equivalent dose (some bleeding and infection issues).
11. Fallout (2)/severe: 4Gy for blood effects (problems with bleeding and infection) and about 0.75 Gy for lethality and GI effects (some small fraction of people will die and others get nausea, vomiting, etc.).

Users have the option of specifying either the number and type or simply the number of casualties who present at their hospital(s). 

If the user specifies only the number of casualties, the model assumes the casualties arriving at the hospital(s) are randomly selected from among all casualties from the attack. The distribution of casualty types in this case is as follow:

Casualty Condition	Percent (1KT)	Percent (10KT)
Burns (1) / moderate: Second-degree burns on hands and face	0.5%	0.1%
Burns (2) / severe: Third-degree burns on hands and face (and first degree over the rest of the body)	0.5%	0.0%
Trauma (1) / people who receive multiple lacerations from flying glass	8.1%	2.7%
Trauma (2) / people who receive blunt trauma	0.1%	0.0%
Trauma (3) / people in collapsed houses and other light buildings	13.5%	65.8%
Trauma (4) / people in collapsed skyscrapers	34.0%	27.3%
Radiation (1) / mild: Nausea, vomiting, anorexia, fever, infections	0.2%	0.0%
Radiation (2) / moderate: More severe mild symptoms, plus bleeding, fatigue, and weakness	0.5%	0.1%
Radiation (3) / severe: More severe moderate symptoms, plus headache, prostration, dizziness ,and disorientation	0.9%	0.0%
Fallout (1) / mild: 1Gy equivalent dose for blood effects, no other equivalent dose (some bleeding and infection issues)	17.7%	1.7%
Fallout (2) / severe: 4Gy for blood effects (problems with bleeding and infection) and about 0.75 Gy for lethality and GI effects (some small fraction of people will die and others get nausea, vomiting, etc.)	24.1%	2.3%

This breakdown by casualty condition is based on work performed during development of the original Surge Model in 2005. In brief, for the nuclear scenarios, we modeled the effects of the blast looking at thermal, radiation, and blast effects at different radii from the center of the attack as well as whether individuals were in direct line-of-sight to the blast or were protected by buildings, walls, or other materials. More specifically:

• Thermal effects are burns received from the thermal heat wave radiating from the blast. Casualties that arrive at the hospital are those who received second- or third-degree burns and exclude those that were vaporized or immediately killed. All these patients also experience radiation effects.
• Blast effects include trauma resulting from the pressure wave of the blast. The pressure will cause the collapse of both skyscrapers and lighter buildings, as well as breaking all the windows of buildings further out. It will also cause flying debris to hit pedestrians. These effects are calculated based on the pressure at each radius and the resultant effects.
• Radiation effects looked at both direct radiation affecting individuals and fallout which can be inhaled for long-term effects. Based upon the exposure and decay rate for these materials, we calculated the likelihood of mild, moderate, and severe radiation and mild and severe fallout.

The distribution of these effects is based upon a fixed weapon size of 1KT or 10KT.

7.2 Casualty Arrival Pattern

Casualties are assumed to present at the hospital(s) when symptoms appear. For this scenario, all patients arrive on Day 1.

7.3 Length of Stay By Hospital Unit

The assumed average length of stay (in days) of patients the ED, ICU, and the floor ( 1-3, 7, 9,10, 15, 16, 20, 25, 26 [for trauma]; 33-38 [for burns] are:

Length of Stay by Unit	Burn 2	Burn 3	Trauma 1	Trauma 2	Trauma 3	Trauma 4	Rad 1	Rad 2	Rad 3	Fallout 1	Fallout 2
ED	1	1	1	1	1	1	1	1	1	1	1
Floor, not via ICU	7	17	5	5	5	5	7	8	14	7	7
Floor, via ICU	7	7	8	8	6	8	4	8	28	4	28
ICU	9	31	10	10	6	6	3	24	30	3	30

7.4 Combined Path Probabilities and Lengths of Stay

The table below shows the assumed probabilities of different "paths" through the hospital(s). 

Path	Burn 2	Burn 3	Trauma 1	Trauma 2	Trauma 3	Trauma 4	Rad 1	Rad 2	Rad 3	Fallout 1	Fallout 2
ED → Discharge	0%	0%	2%	0%	0%	0%	0%	0%	0%	0%	0%
ED → Death*	0%	0%	0%	0%	0%	0%	0%	0%	0%	0%	0%
ED → Floor → Discharge	6%	0%	54%	31%	9%	6%	80%	46%	2%	67%	6%
ED → Floor → Death	0%	0%	0%	0%	16%	11%	10%	4%	1%	8%	1%
ED → Floor → ICU → Death	0%	0%	6%	3%	1%	1%	0%	14%	6%	0%	2%
ED → Floor → ICU → Floor → Discharge	4%	0%	9%	5%	1%	0%	0%	9%	1%	0%	0%
ED → Floor → ICU → Floor → Death	0%	0%	1%	1%	3%	2%	0%	1%	1%	0%	0%
ED → ICU → Death	7%	53%	10%	21%	16%	19%	1%	14%	71%	2%	71%
ED → ICU → Floor → Discharge	82%	45%	16%	34%	13%	6%	9%	10%	9%	22%	9%
ED → ICU → Floor → Death	0%	3%	2%	5%	41%	56%	0%	1%	10%	1%	10%

* By definition no trauma patients admitted to the hospital(s) were dead on arrival (DOA)

The breakdown of length of stay by patient type summed over all paths is:

Average Length of Stay by Patient Outcome	Burn 2	Burn 3	Trauma 1	Trauma 2	Trauma 3	Trauma 4	Rad 1	Rad 2	Rad 3	Fallout 1	Fallout 2
Survivors	16.56	39.00	10.16	13.44	10.39	10.66	8.00	16.54	52.67	8.00	38.85
Fatalities	6.59	16.13	8.93	8.27	7.40	8.10	4.87	14.28	16.70	4.71	16.41
Average Combined	15.75	26.34	9.92	11.88	8.07	8.40	7.64	15.75	20.85	7.63	19.90

7.5 Overall Outcome Probabilities

Based on these inputs (1-3, 7, 9,10, 15, 16, 20, 25, 26 [for trauma]; 33-38 [for burns], the overall discharge and death probabilities are:

Outcome	Burn 2	Burn 3	Trauma 1	Trauma 2	Trauma 3	Trauma 4	Rad 1	Rad 2	Rad 3	Fallout 1	Fallout 2
Discharge	92%	45%	81%	70%	22%	12%	89%	65%	12%	89%	16%
Death	8%	55%	19%	30%	78%	88%	11%	35%	88%	11%	84%

7.6 Resources Consumed Per Patient Per Day

The assumed level of resource consumption per patient per day is shown in the table below:

Resource	Units	Category	Subcategory	Lambdaa	Burns-Moderate			Burns-Severe			Trauma-Lacerations			Trauma-Blunt
					ED	ICU	Floor	ED	ICU	Floor	ED	ICU	Floor	ED	ICU	Floor
Med/Surg bed	One Bed	Capacity	Floor	1	0.083	0	0	0.083	0	0	0.083	0	0	0.083	0	0
ICU bed	One Bed	Capacity	ICU	1	0	1	0	0	1	0	0	1	1	0	1	1
Burn bed	One Bed	Capacity	Burn	1	0	0	1	0	0	1	0	0	0	0	0	0
Operating room	One OR Suite	Capacity	OR	1	0.083	0	0	0.25	0	0	0.042	0	0	0.167	0	0
Airborne isolation room	One Bed	Capacity	Isolation	0.9	0	0	0	0	0	0	0	0	0	0	0	0
Intensivists (CCM)	FTE	Staff	CCM	0.7	0.083	0.083	0	0.083	0.083	0	0.083	0.083	0	0.083	0.083	0
Critical care nurses (CCN)	FTE	Staff	CCN	1	0.167	0.5	0	0.333	0.5	0	0.125	0.5	0	0.25	0.5	0
Surgeons	FTE	Staff	Surgeon	0.3	0.33	0.25	0.083	0.33	0.25	0.083	0.167	0.167	0.042	0.167	0.167	0.042
Non-intensivists (MD)	FTE	Staff	MD	0.9	0.167	0	0.042	0.167	0	0.042	0.167	0	0.042	0.167	0	0.042
Non-critical care nurses (RN/LPN)	FTE	Staff	RN	1	0.042	0	0.146	0.042	0	0.146	0.042	0	0.146	0.042	0	0.146
Respiratory therapists (RT)	FTE	Staff	RT	0.7	0.083	0.083	0.042	0.083	0.083	0.042	0.083	0.083	0.042	0.083	0.083	0.042
Radiology machines	Machine Time	Lab/Radiology	Radiology	0.3	0.021	0.021	0	0.021	0.021	0	0.042	0.042	0	0.042	0.042	0
Radiologic technicians	FTE	Staff	Rad Tech	0.3	0.021	0.021	0	0.021	0.021	0	0.042	0.042	0	0.042	0.042	0
Pharmacists (PharmD/RPh)	FTE	Staff	Pharmacist	0.7	0.021	0.042	0.042	0.021	0.042	0.042	0.021	0.042	0.042	0.021	0.042	0.042
Mechanical ventilator	Machine Time	Capacity	Ventilator	0.9	1	1	0	1	1	0	1	1	0	1	1	0
Ventilator equipment	One Ventilator	Equipment	Vent Tubing	0.9	1	1	0	1	1	0	1	1	0	0	1	0
Oxygen (O2)	24h O2 for Vent	Supplies	Oxygen	0.9	1	2	0	1	2	0	1	2	1	1	2	1
Oxygenation monitoring equipment	Machine Time	Equipment	O2 Monitoring	0.9	0.167	1	1	0.333	1	1	0.125	1	1	0.25	1	1
Surgical supplies	Trauma Set	Supplies	Surgical	0.3	1	0.25	0.125	1	0.25	0.125	1	0.25	0.125	1	0.25	0.125
Radiology supplies	Radiographic Film	Supplies	Radiological	0.3	1	1	0	1	1	0	1	1	0	1	1	0
Ciprofloxacin or doxycycline	400mg/100mg bid	Pharmacy	Antibiotics	1	0	0	0	0	0	0	0	0	0	0	0	0
Rifampin or other 2nd line agent	600mg po bid	Pharmacy	Antibiotics	1	0	0	0	0	0	0	0	0	0	0	0	0
Antibiotics for secondary pneumonia	Assorted	Pharmacy	Antibiotics	1	0	1	0	0	1	0	0	1	0	0	1	0
Surgical Infection prophylaxis/treatment	Assorted	Pharmacy	Antibiotics	1	1	1	1	1	1	1	1	1	1	1	1	1
Neutropenia prophylaxis/treatment	Assorted	Pharmacy	Antibiotics	1	0	0	0	0	0	0	0	0	0	0	0	0
Antibiotics intravenous infusion set	One IV Piggyback	Supplies	IV set	1	1	0.5	0.5	1	0.5	0.5	1	0.5	0.5	1	0.5	0.5
Hemodynamic medications	Assorted	Pharmacy	Hemodynamic	0.7	0	0	0	1	1	0	0	0	0	1	1	0
Intravenous fluids	24h LR or equiv.	Pharmacy	IVF	0.7	1	1	1	1	1	1	1	1	1	1	1	1
Intravenous infusions set	One IV Set	Supplies	IV Set	0.7	1	1	1	1	1	1	1	1	1	1	1	1
Laboratory machines	Machine Time	Lab/Radiology	Laboratory	0.7	0.083	0.083	0.042	0.083	0.083	0.042	0.083	0.083	0.042	0.083	0.083	0.042
Laboratory supplies	CBC/CMP Reag.	Supplies	Laboratory	0.7	2	2	2	2	2	2	2	2	2	2	2	2
Temperature monitoring equipment	Machine Time	Equipment	Temperature	1	0.167	1	1	0.333	1	1	0.125	1	1	0.25	1	1
Thromboembolism prophylaxis	Enoxaparin 40mg sc qd	Pharmacy	DVT Prophylaxis	1	0	1	0	0	1	0	0	1	1	0	1	1
Urine output monitoring equipment	Catheter and Bag	Equipment	U/O	1	0	1	0	0	1	0	0	1	1	0	1	1
Universal precautions PPE	Glove/gown/mask	PPE	Universal	1	1	1	1	1	1	1	1	1	1	1	1	1
Chemical PPE	Level D	PPE	Chemical	0.3	0	0	0	0	0	0	0	0	0	0	0	0
Radiological PPE	Level D	PPE	Radiological	0.3	1	1	0	1	1	0	1	1	0	1	1	0
Waste disposal	Level D	PPE	Decon Waste	0.3	1	1	1	1	1	1	1	1	1	1	1	1
Mortuary decontamination materials	Level D	PPE	Mortuary	0.3	0	0	0	0	0	0	0	0	0	0	0	0
Atropine sulfate	2mg	Pharmacy	Atropine	0.1	0	0	0	0	0	0	0	0	0	0	0	0
Pralidoxime	2g	Pharmacy	Pralidoxime	0.1	0	0	0	0	0	0	0	0	0	0	0	0
Diazepam	10mg	Pharmacy	Diazepam	0.1	0	0	0	0	0	0	0	0	0	0	0	0
EEG	Machine Time	Equipment	Chemical	0.1	0	0	0	0	0	0	0	0	0	0	0	0
IV steroids	Hydrocortisone 50mg IV q6h	Pharmacy	Steroids	0.7	0	0	0	0	0	0	0	0	0	0	0	0
DPTA	1g IV	Pharmacy	DPTA	0.1	1	1	1	1	1	1	1	1	1	1	1	1
Prussian blue	3mg po tid	Pharmacy	Prussian Blue	1	1	1	1	1	1	1	1	1	1	1	1	1
Growth factors	Pegfilgrastim 6mg sc qw	Pharmacy	Growth factors	1	1	1	1	1	1	1	0	0	0	0	0	0
Stem cell transfusion	Unit of Use	Heme/Onc	Stem Cell Trans	1	0	1	0	0	1	0	0	0	0	0	0	0
Geiger counter	Machine Time	Equipment	Radiation	0.1	0.42	0.21	0.21	0.42	0.21	0.21	0.42	0.21	0.21	0.42	0.21	0.21
Enteral feedings (3/day/patient)	Unit of Use	Nutrition	Enteral	1	0	0.5	0	0	0.5	0	0	0.5	0	0	0.5	0
Oral food (3 meals/day/ patient)	Unit of Use	Nutrition	Oral	1	0	0.5	1	0	0.5	1	0	0.5	1	0	0.5	1
Sheet change	1 linen change	Housekeeping	Laundry	1	1	1	1	1	1	1	1	1	1	1	1	1
Patient infection control	FTE	Epidemiology	Infection Control	0.5	0.042	0.042	0.021	0.042	0.042	0.021	0.042	0.042	0.021	0.042	0.042	0.021
Engineering	FTE	Engineering	Facility	0.7	0.042	0.083	0.042	0.042	0.083	0.042	0.042	0.083	0.042	0.042	0.083	0.042
Janitorial/Housekeeping	FTE	Housekeeping	Janitorial	1	0.125	0.125	0.083	0.125	0.125	0.083	0.125	0.125	0.083	0.125	0.125	0.083
Nutrition	FTE	Nutrition	Counseling	0.5	0	0.083	0.083	0	0.083	0.083	0	0.083	0.083	0	0.083	0.083
Psychological support	FTE	Ancillary	Psychologist	0.5	0	0	0.042	0	0	0.042	0	0	0.042	0	0	0.042
Mortuary	FTE	Mortuary	Morgue	0.1	0	0.042	0.042	0	0.042	0.042	0	0.042	0.042	0	0.042	0.042

^a Lambda captures the resource requirement decay rate for a resource. Lambda = 1 implies no decay; the patient requires a constant amount of the resource while s/he is hospitalized. Lambda <1 implies that less of the resource is required each day the patient is hospitalized. Go to section 2.2 for details.

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