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OCR for page 251
The Medical Implications of Nuclear War, Institute of
Medicine. ~ 1986 by the National Academy of Sciences.
National Academy Press, Washington, D.C.
Burn and Blast Casuallies:
Triage in Nuclear War
JENNIFER LEANING, M.D.
Harvard Community Health Plan, Boston, Massachusetts
THE CONCEPT OF TRIAGE
During the last century, events creating large numbers of casualties
have, with infrequent but depressing repetition, absorbed the attention of
the world community. In these years, nations have increased to sufficient
population densities and have developed technologies of sufficient power
to create the conditions for sudden catastrophe, whereby in a relatively
brief time span an enormous number of people may be killed or injured.
When discussing nuclear war, reference to precedent may admit sources
of serious error, since in terms of scale of effects, this disaster would
depart fundamentally from anything the world has yet experienced. Yet
people still struggle to comprehend what nuclear war might mean, if only
. As part of this attempt to make real the
unimaginable' it is instructive to inquire into how massive numbers of
to give better warning now
casualties have been managed in the past. The perspective taken here is
the organization of medical response. Wars and major civilian disasters
provide the context and the time frame dates from the U.S. Civil War.
The current theory of mass casualty management rests on the concept
of triage, according to which casualties are sorted into categories by
severity of injury and treatment plans assigned to each based on assessment
of transport availability and resources. The word is said to derive from
the French triage, meaning the process of sorting by quality, and its use
in the wool and coffee trades during the eighteenth and nineteenth centuries
carried the distinct connotation of separating higher from lower quality. ~
Although the process of prioritizing military casualties on the basis of
251
1
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252
HEALTH CONSEQUENCES OF NUCLEAR WAR
wound severity has been traced to Baron Dominique Jean Larrey, surgeon
in chief of Napoleon's Russian Campaign, 2 the term triage was first
applied in this context during World War I.3 The British Expeditionary
Force used triage to mean division into three: those who could withstand
travel back from the front, those who required immediate surgery, and
those whose injuries were so severe that they would be left to die.4 The
U.S. military command currently prefers the term sorting, but in all other
respects relies on the concept of triage in its protocols for mass casualty
management.5
The principle of sorting casualties into categories carries both technical
and ethical complexities. To sort is to assign value, according to a system
that may or may not be explicit. In modern casualty medicine, this system
must also respect the issue of time. Medical understanding and skill have
advanced to the point at which salvage of the severely injured can be
accomplished if intervention proceeds within 6 to ~ hours.6 In settings in
which resources are ample and accessible, the act of triage devolves into
a straightforward organizing technique. For the sake of clarity and eff~-
ciency, the most severely injured get treated first, and the less severely
injured get treated second. All casualties are assured of rapid assessment
and appropriate disposition; all are assured of receiving the best care in
adequate time. The triage technique requires experience and skill, and
consequently, in well-designed mass casualty systems, it is the most sea-
soned medical officer who takes on this task.7
Ethical issues intrude in settings of relative resource scarcity, which
often pertain to mass casualty situations. The code of ethics for physicians,
which has evolved over centuries, squarely assigns to the physician the
responsibility of protecting the interests of the individual patient in all
situations. The physician is enjoined to refrain from a calculus that in-
corporates any consideration other than the patient's well-being.8 When
resources are perceived as scarce, however, other social or institutional
values weigh in and attempt to influence physician choice and behavior.
In peacetime, as technology has offered technically feasible but expensive
possibilities for individual salvage, society has begun to debate cost-benef~t
ratios in health care, a discussion fraught with ethical complexity for
physicians as practitioners and for society as a whole.9 In mass casualty
situations, triage decisions provide ample opportunities for ethical analyses
that lie outside the scope of this discussion. In the absence of an explicit
ethical code for physicians in settings in which need has far outstripped
the available capacity to respond, it has become accepted practice to assign
top priority to those who, without intervention, would otherwise die.~°
All other casualties, who would live despite initial delay in transport or
treatment, are relegated to lower-priority categories. Those who would
die regardless of treatment are assigned to the category of lowest priority. ~ ~
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BURN AND BLAST CASUALTIES: TRIAGE lN NUCLEAR WAR
253
The underlying principle at work is to provide the greatest good, defined
as life, for the greatest number, defined as all casualties. i2 According to
this principle, it is unsound medical practice to devote time and resources
to someone whose chances of living in any case are minimal, at the cost
of losing the lives of some who could very well be salvaged.
The principle of maximizing the number of lives that can be saved,
although axiomatic to those in emergency and trauma medicine, in actual
situations translates into some exceedingly difficult ethical decisions. The
process can succinctly be illustrated as follows:
Typically, a hospital with only a limited supply of blood on hand and with little
likelihood of more becoming available in the near future will use that blood so
as to aid in the recovery of the largest number of injured. On this basis, the
critically wounded man who would require all of the only 10 units of blood
available in order to aid in his possible recovery would drop in priority to a
position below that of the five casualties whose recovery would be assured by
the receipt of 2 units each. Conversely, where only 2 units of blood are on hand
to treat the shock of 10 casualties, the best utilization of this item would entail
using it in the resuscitation of no more than one or two of these casualties rather
than wasting it by giving each only 1/5 unit. ~3
The process of sorting according to this principle of extending life to the
largest number of people, as much as it is at a variance with the ethical
approach of the individual physician to his or her individual patient, has
come to be accepted by both the profession and society in general when
it is invoked in settings of plenty, to sort for the sake of efficiency, and
in settings of scarcity, to sort so that the greatest number of casualties
may survive.
Triage during wartime conforms to a different principle. As a particular
and relatively modern aspect of military medicine, the concept of triage
reflects the interest of the military leadership in maximizing the fighting
capacity of the force. ~4 Sorting of casualties appears to date from the era
of standing armies, during which, from the perspective of military effi-
ciency, casualties were seen, first, as encumbrances.~S During the wars
of the seventeenth and eighteenth centuries, this interest of the military
command extended to identifying those too injured to continue fighting
and removing them from the path of the advancing or retreating armies. 16
Although over the centuries the record abounds with examples of the ways
in which military administrators and individuals and groups within the
physician and religious communities participated in preventive and re-
habilitative care of the soldier, ~7 the injection of a more humane spirit in
the systematic approach to casualties took the influence of several factors
that were at work in the nineteenth century.
During this period, significant sections of civilian elites witnessed the
battlefield horrors at the Crimean and U.S. Civil wars. Their outcry and
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HEALTH CONSEQUENCES OF NUCLEAR WAR
subsequent efforts contributed greatly to the transport and resource systems
that supported military medicine in World War I. ~8 Second, developments
in weapons technology began to inflict an increasingly high proportion of
injures at a time when engagements were still decided by how many
soldiers were on the field. The military began to place a premium on
returning the maximum number of soldiers to active duty as soon as
possible. For all conventional wars in the twentieth century and in current
North Atlantic Treaty Organization (NATO) protocols for nuclear war,
this same instruction has been given to military physicians. i9 The third
factor in the shift from getting nd of the wounded to returning them to
battle has been progress in medical skill and knowledge. Especially since
the latter part of World War II, military physicians have had at their
command a significant range of techniques and interventions that can
markedly alter the morbidity and mortality of casualties from conventional
war.20 It has been precisely during this time frame that the dilemma for
military physicians has been the most intense: equipped with the skills to
save the severely injured, in the setting of resource scarcity physicians
are constrained by military guidelines not to carry out triage according to
salvage of life but according to salvage of fighting capacity. As General
Patton is said to have enjoined a group of medical officers in Casablanca
in 1943:
If you have two wounded soldiers, one with a gunshot wound of the lung, and
the other with an array or leg blown off, you save the s.o.b. with the lung wound
and let the g.d.s.o.b. with an amn~ltntP.`l arm or 1P.S, OO try hPl1 HP ;Q nix ~ r1 11Q"
to us anymore.21
~1~1~ ~1 :1 ~ _ ~my_ ~^w _ _ _ · 1 ·. _ _ 1 · ~
~--AN ~^ A_ t ~_ ~~ ~^ ~4 4_ $ ~AAV ~ - ~ - ~1~
111~; ull~IArlIIlas lor me mllllaIy pnyslclan In a mass casualty situation,
in which he or she is asked to function as a triage officer, structured
according to the military principle of maximizing the fighting force, are
not directly addressed in the Geneva Conventions of 1949, which affirm
even in time of war the physician's personal responsibility for the care of
the individual patient and define the limits within which a military or
political bureaucracy can intrude upon that obligation.22 The World Med-
ical Association in 1956 prepared a statement on the code of ethics for
physicians in wartime, referring obliquely to this triage dilemma, by re-
jecting all forms of distinction among patients "except those justified by
medical urgency...."23
The ethical questions involved in military triage become even more
complex as weapons of mass destruction threaten to engulf the civilian
noncombatant population as well as the military force. The military, with
some support from civilians within the medical ethics community, 24 has
a clear point of view. In mass casualty settings involving both civilians
and soldiers, the role of the military medical officer is to concentrate first
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BURN AND BLAST CASUALTIES: TRIAGE IN NUCLEAR WAR
255
on the combatant military force. as The NATO field manual on emergency
war surgery devotes several pages to careful explication of this principle,
concluding:
Even in the thermonuclear age, however, the basic principle of military medicine
remains unchanged. It is, as it has always been, the salvage of the greatest possible
number of lives for the support of the military mission.26
In this regard the Geneva Conventions are also silent, perhaps not
anticipating the extent to which military war might extend to mass civilian
catastrophe.
EXPERIENCE WITH MASS CASUALTY MANAGEMENT
Triage protocols have defined the organization of medical management
of mass casualties by framing the problem in terms of where to do what
to whom when. The actual details of how medical response is mobilized
and how the outcome is achieved have always had to conform to two key
variables defined by the existing situation: available modes of transpor-
tation and relative reserves of resources. A brief account of military man-
agement of mass casualty medicine during the last 150 years demonstrates
the increasing capacity of the medical profession to manage the care of
large numbers of injured people and Illuminates tne ways In wn~cn one
variables of field conditions and resources have always imposed limits on
medical response and shaped triage protocols
- r
~· ~ ~· ~^1 ~.u ~u 4 ~ A
The record also reveals the paradoxical effects of technology. As the
weapons of war have been perfected to inflict a wider variety and pro-
portionately greater number of battlefield casualties, the innovations in
response (transport, facilities, understanding, skill) have not only more
than kept pace but have in fact occurred in large part because of the
challenge of war. The management of complex medical and surgical prob-
lems has taken quantum leaps during and after each war of the twentieth
century, and the tenets of civilian mass casualty medicine derive directly
from this military experience. Since the last world conflict, the technology
of war has taken another quantum leap, raising again the question of
medical response. The medical community has evolved, as will be dis-
cussed, a serviceable system for what has been encountered in the past.
The issue is how it would fare in the setting of nuclear war. In tracing
the development of mass casualty medicine, I outline here a history that
may or may not prepare us to meet the possible near future.
The U.S. Civil War
In the early years of the U.S. Civil War, a principal problem in treating
the wounded was geKing to them. Neither the North nor the South had
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256
HEALTH CONSEQUENCES OF NUCLEAR WAR
developed transport systems for the retrieval of battle casualties, yet the
new rifles and artillery used during this war exacted an unprecedented
toll.27 Contributing to the increased destructive power of the infantry on
both sides were the breech-loading magazine rifles and the Minie rifled
bullet, accurate to 500 yards (which replaced muzzle-loading flintlock
rifles with accuracy only up to 200 yards), and the widespread heavy use
of artillery batteries comprised of 6-pounder bronze guns and 12-pounder
bronze howitzers. Cavalry charges and bayonet warfare slipped into the
past. 28
After the Second Battle of Bull Run (August 29-30, 1862), the fields
were strewn with the dead and injured: 1,747 killed and 8,452 wounded
on the Union side; 1,481 killed and 7,627 wounded on the Confederate
side.29 Despite substantial improvement in transport services since the
First Battle of Bull Run almost a year earlier, the casualties from this
engagement lay on the field for days. At both these battles, outraged
civilians organized cavalcades of volunteers from adjacent towns to go in
with wagon trains, gather up the wounded who were still alive, and bring
them to whatever hospitals were available. In response to public pressure,
Dr. Jonathan Letterman was appointed Medical Director of the Army of
the Potomac and by 1864 had organized an ambulance corps for the entire
Union Army, providing each regiment with four horse-drawn wagon am-
bulances and drivers. The South could not marshal! the resources to support
such a system, which, even at its best, was routed or overwhelmed by
the heaviest battles of the war.30
Delivery of care was also impeded by available resources. Organizing
an effective medical response during the Civil War was complicated by
the fact that the lines of battle moved rapidly and unpredictably. The
establishment of a secure forward medical station was fraught with hazard.
Yet it was found that carrying casualties by horse-drawn wagon or cart
to field hospitals 5 to 10 miles distant from the front inflicted great hardship
on all casualties and increased morbidity and mortality.3i In this setting,
the heroic battlefield interventions attributed to Clara Barton and others
make much medical sense.32 It has become a standard of mass casualty
medicine that the more distant and inaccessible the site for definitive care,
the more extensive must be the on-site treatment.
It was apparent even to the medical providers at the time that although
it was important to remove casualties from the battlefield in order to be
able to care for them, and although it was prudent to remove them beyond
the reach of the next day's front line, subsequent questions about where
to do what had no clear answers. The field hospitals were poorly equipped,
the physicians lacked knowledge, if not experience, and the rear hospitals,
whether Union or Confederate, offered little more technological or material
. . . - . ~
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.B URN AND BLAST CASUALTIES: TRIAGE IN NUCLEAR WAR
257
support than whatever the armies could drag with them.33 The role of the
military physician in the Civil War, and in other wars waged with similar
technologies and supported by similar levels of medical understanding,
acquired at best a humanitarian function. There were so few technically
effective interventions known to physicians that removing the wounded
from cold damp fields and placing them in bed, giving them food and
water, and administering whiskey and morphine constituted the essence
of appropriate treatment. Whatever else physicians attempted (amputa-
tions, applications of poultices and liniments, experimental explorations
under ether or chloroform) were as likely to add to patient morbidity as
to detract from it. Deep wounds of the thigh with fracture of the femur
earned fatality rates of 50 percent if not treated, and 34-70 percent if
treated.34 Abdominal wounds were usually fatal and were found in about
one-tenth of those dying on the field.35 Those with upper limb and su-
perf~cial scalp wounds were most likely to survive, perhaps chiefly because
they could wale off the battlefield and seek help on their own.36 An
authoritative summary of military casualties from the Civil War suggests
that on both sides as many soldiers died from their wounds as were killed
outr~ght,37 a ratio that is difficult to compare with modern statistics because
of the delay that transport conditions introduced between the time of injury
and the time of treatment. The Civil War data do show, however, that
death from disease was more than double the overall mortality from bat-
tlefield wounds.38 Inpatient mortality from local wound infection ranged
from 40 to 60 percent; if bacteremia ensued, mortality was virtually as-
sured.39 Of those who developed tetanus in the hospital, 89 percent died.40
Poor water, inadequate hygiene, overcrowding, and malnutrition, all of
which are factors that defined the hospital environments at field and rear
echelons, also proved major determinants of outcome among hospitalized
casualties.4~
World War l
During World War I, innovations in transport and treatment at a forward
medical station created conditions for developing distinct stages in the
management of battle casualties. The advent of motorized ambulances
(drawn out of the Letterman tradition and used first by the British during
the Boer War) permitted the rapid removal of casualties from the initial
triage site, the Regimental Aid Post, to the casualty clearing station (CCS).
Situated within a few miles of the front line, the CCS afforded medical
personnel an enclosed, moderately well-equipped, rudimentary hospital
which, by design, could be swiftly packed up and moved if the tactical
situation required immediate retreat.42 As it turned out, however, this
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HEALTH CONSEQUENCES OF NUCLEAR WAR
mobility was unnecessary because the front lines in World War I proved
relentlessly stable. Innovations in artillery (quick-firing, nonrecoiling car-
tridges with ranges up to 3,000 yards) inflicted enormous numbers of
casualties43 (60,000 British were killed or wounded in the first day of the
Battle of the Somme).44 These weapons were supplemented by the per-
fected magazine rifle, which was accurate up to 2,000 yards, and the
water-cooled, hand-held machine gun.45
The fixed forward lines on the European front allowed for detailed
stratification of care by geographic location. The CCS was initially set
up to handle 200 casualties per day. The work consisted primarily of
sorting, bandaging, and returning to the field those who could still fight
or sending the more seriously wounded by ambulance back to the rear.
Facilities were available to hold casualties at the site for 1 to 3 days. As
evidence began to accumulate about the morbidity of casualties handled
in this way, however, and as physicians became more experienced in the
treatment of traumatic injury, the techniques used at the CCS evolved into
a more complex and almost comprehensive approach to care. The CCS
became, in effect, a semipermanent triage and treatment center, with
facilities that allowed postoperative cases to stay for 1 to 3 weeks.46
The relative stability of the front, the extensive supply lines that could
thus be set up and maintained, and the motorized transport services allowed
physicians at the CCS to develop increasingly aggressive techniques and
test out increasingly explicit treatment guidelines. By the end of the war,
wound care consisted of wide debridement and excision (the risk of gas
gangrene from wounds incurred in the Belgian and French countryside
had become well recognized) and local application of antiseptic wound
packs. The patients were then sent back from the front for more definitive
care (delayed primary closure) at the rear hospitals. Those arriving off the
field with impending shock were wrapped in warm blankets, given oral
fluids if they could still swallow and intravenous gum acacia solutions if
necessary and if available, and rushed by ambulance back to the field
hospital. Many died in transit, and others arrived at the field hospital
profoundly hypovolemic as they faced immediate surgery. Casualties ar-
riving at the CCS who were already in frank shock were given fluid
resuscitation (the widespread use of blood and plasma awaited collection
and storage methods not developed until the latter part of World War II),
and thoracic and abdominal explorations might have been attempted. The
issue of when, then, to transport the postoperative survivors remained
unresolved. Burn cases were wrapped in gauze and sent back from the
front; at the field hospital the dressings were changed and the patients
were put to bed. The incidence of shock in burn patients was underesti-
mated, although by the end of the war it became general practice to refrain
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BURN AND BLAST CASUALTIES: TRIAGE IN NUCLEAR WAR
259
from frequent dressing changes in order to reduce the risk of infection.47
Organized to manage casualties by these guidelines, the CCS at its peak
could accommodate over 1,000 admissions per day. Data from the Battle
of the Somme in July 1916 indicate that on the first day 14,400 men were
admitted to 13 clearing stations; on the second day, 13,806 were admitted,
and on the third day 8,793 were admitted.48 This influx stretched medical
capacities to their limits, and the experience has been cited later by senior
medical officers as reflecting the utmost in medical organization and dis-
cipline.49
Despite the advances in surgical assessment and technique forged during
this war, the initial delay in retrieving the wounded from the field and
bringing them to the Regimental Aid Post often stretched for hours, oc-
casionally days. Many of the most seriously injured died before they were
reached by the stretcher-bearers, whose round trip from field to aid post
and back averaged 1 hour. Each battalion had 32 stretcher-bearers, but in
some of the heavier battles of this war, every battalion suffered hundreds
of casualties.50
Worm War lI
The improved motor vehicle technology that sustained the mobility of
all armies in World War II made the Allied front fluctuate far more swiftly
and dramatically than it had in World War I.si These fluid field conditions
also made forward placement of complex medical response units much
more problematic. The technological innovations in offensive military
vehicles had not yet extended to the transport systems for removing the
injured from the scene of battle, so that paradoxically the imbalance
between fighting mobility and speed of medical retrieval paralleled the
situation in the U.S. Civil War more than that in World War I. The major
new weapons of World War II were the tank and the tactical airplane,
overpowering well-equipped infantry and rendering distinctions between
land and sea warfare obsolete.52
Forward clearing stations were far flung and forced by rapid shifts in
battle lines to curtail capacities for intervention. Yet at the same time
medical knowledge had advanced to the point at which it was becoming
increasingly apparent how much could be done during the first 6 to 8
hours of resuscitation if the resources were at hand. The lifesaving potential
of fluid replacement in the treatment of burns and the use of plasma and
blood transfusions preoperatively in the stabilization of those with serious
traumatic injury had become extensively appreciated techniques. Penicillin
was first widely used in the treatment of battle wounds during the early
part of 1943 at the start of the Italian campaign and heralded the enormous
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HEALTH CONSEQUENCES OF NUCLEAR WAR
importance of antibiotics in determining medical outcome. The practice
of exploring penetrating wounds of the thorax and abdomen had become
routine, and much discussion surrounded the management of bowel in
c~
Jurles.=J
The combination of increased medical understanding about how to sal-
vage the severely injured with the difficulties in securing a stable forward
treatment base forced World War II physicians into finely developed
assessments of when to time critical interventions. The morbidity attached
to the postoperative transport of patients with bowel injuries and the high
incidence of hypotension in seriously burned patients presented particu-
larly acute dilemmas to a medical service that could not, owing to the
tactical situation, count on being in one place for more than 12 hours.
Senior medical officers began to devise tight and detailed triage protocols
and undertook systematic evaluations of front line casualty experiences.
Their memoranda provide a terse and intense record of how informed,
observant, and pragmatic physicians attempted to construct from their
daily practice a manual of military medicine that could promise the injured
the best care possible in circumstances that were constantly shifting.54
The Vieinam War
The helicopter revolutionized military medical care. s, Developed during
the latter years of the Korean War and introduced gradually during the
Vietnam War, the helicopter permitted the immediate extrication of the
injured and the rapid transit over insecure territory to a field hospital where
major stabilization and, often, definitive care could be delivered. Over
the years of this war, the field hospital structure increasingly conformed
to the geography of the battlefield. In Vietnam there were no front lines.
Pockets of intense engagement riddled the countryside, and areas of rel-
atively permanent safety were located within 30 to 40 miles (about 48 to
64 km) of these war zones. The concept of the field hospital supported
by the full-service hospital in the rear secure zone telescoped into a flexible
system of clearing stations, hospitals and the MUST (Medical Unit, Self-
Contained, Transportable) unit. First deployed in 1966, the MUST unit
evolved into the site for the delivery of much definitive care. Soldiers
injured in the field were picked up by medical evacuation teams assigned
to helicopters, carried by helicopter to the semipermanent MUST hospitals,
and given whatever treatment they required. If their injuries were suffi-
ciently severe as to eliminate the possibility of return to combat or if
convalescence were to extend beyond 30 days, soldiers would be sent by
C-141 transport plane to major offshore hospitals. This combination of
secure bases in transport proximity to the war zones and rapid retrieval
afforded by the helicopter transformed the concept of casualty sorting at
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BURN AND BLAST CASUALTIES: TRIAGE IN NUCLEAR WAR
261
the front into a process less fraught with hard decisions.56
The new weapons used in Vietnam (high-velocity, lightweight rounds
from the M16 and AK47 rifles, claymore mines, fragmentation grenades,
varieties of cluster bombs and booby traps, phosphorus and napalm chem-
icals) inflicted particularly severe and dirty wounds.57 Casualties in the
Vietnam War experienced an increased incidence of small fire injuries
with a relatively higher proportion of trunk wounds.58 As the medical
capacity to intervene improved during these years, the question of resource
availability at the front might have been expected to move into increasingly
sharp focus. During the Vietnam War, however, the medical resource
systems and the casualty transport systems kept pace with each other and
with the pace of medical technology. U.S. military hospitals never lacked
blood, receiving shipments of more than 350,000 units during the peak
year of 1968.59 Sophisticated radiology and operating suites relied on
plumbing and generator systems installed on site at the MUST units; and
the most complex cardiac, vascular, and neurosurgical procedures could
be accomplished within a 30-minute helicopter ride from the combat zone.60
The hospitalized mortality rate for wounded casualties in Vietnam dur-
ing the 5-year period from 1965 to 1970 was 2.6 percent, compared with
4.5 percent in World War II, 8.1 percent in World War I, and 14.1 percent
in the U.S. Civil War.6~ This decline in mortality occurred despite the
successful helicopter evacuation to hospitals of those so severely injured
that, in earlier wars, they would have died on the field or in transit. This
decline is due in part to the speed with which the injured were transported
to the source of care. Since the U.S. Civil War, the delay from time of
injury to time of first aid has been much reduced, compressed from several
days in the early years of that war to within 1 day during World War I,
to a few hours in World War II, and a matter of 15 to 45 minutes during
the Vietnam War.62
This decline in mortality is also due to the resources available at the
site of care. As an index of medical effectiveness, the U.S. Army employs
the concept of "deaths as a percent of hits," or the ratio of deaths to
deaths plus surviving wounded. For World War II, the ratio was 29.3
percent, and for the Vietnam War, the ratio was 19 percent.63 The average
inpatient length of stay was reduced from 80 to 63 days, and, reflecting
progress in vascular surgical practice, the amputation rate for those with
significant arterial and venous injury was 13 percent during the Vietnam
War, compared with 49 percent during World War II.64
Summary of Experience from Conventional War
Although the course of military medicine in the last century has been
characterized by significant discontinuities, as one generation of military
OCR for page 273
273
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274
HEALTH CONSEQUENCES OF NUCLEAR WAR
approximately 1.6 miles (about 2.6 km) wide and 62 miles (about 100
km) around the zone of total destruction. This site, the area of several
fronts in World Wars I and II, would constitute the triage location-
adjacent to the devastation, it would be the first stop for all seeking help.
In terms of infrastructure damage and social regrouping, it corresponds rough-
ly to the 2-4-km zone around ground zero in Hiroshima.
The terrain would have sustained blast waves of 1.S to 2 psi, which is
sufficient to destroy much of the building stock and disrupt roads and
bridges throughout. (The model of Daugherty et al. ins discusses the pos-
sibility of scattered secondary fires in this zone.) During the first day, the
winds would probably be in the range of 30- to SO-mile per hour (about
48 to 80 km per hour). These winds would be filled with hot and toxic
fumes from the central fire zone.
From the standpoint of setting up a medical triage system in this setting,
the first issue to determine is that of timing. Can transport or medical
resources be marshalled sufficiently to make it possible to intervene during
the critical 6 to ~ hours during which all salvage of the seriously injured
must take place? Timing will cease to exist as the critical variable when
lack of transportation or resources, relative to numbers of casualties,
precludes complex medical intervention. At that point the triage protocols
for mass casualties would be reduced to a most austere mode, and medical
management, if the term can still be used, would revert to that of another
era. In the reference case used here, both factors (overwhelming numbers
and resource scarcity) apply in full force even at the relatively constrained
end of the spectrum of possible attack parameters. Here the example of
New York City is discussed.
In the first few hours, at a rate dependent at least in part on road and
fire conditions, physicians would begin to congregate at whatever health
facilities remained standing. Including those physicians in the 12-lS-km
zone and those from the 15-18-km zone, in New York City there would
be approximately 1 physician for every 72 people injured from the bomb-
ing. In the U.S. Civil War, approximately 16,500 physicians enrolled on
both sides were involved in treating 318,200 wounded, yielding a ratio
of 1 physician for every 19 injured people.~09
Each physician would have to choose between two strategies: one of
rapid triage and one that essentially abandons triage and treats each patient
in order, a serial pattern described among Japanese physicians during the
first several days after the bombings. In rapid triage, the physician would
move quickly from one casualty to the next, assigning each to a treatment
category, carrying out the role of labeling victims, but not treating them.
In the reference case setting, in which the capacity to deliver advanced
care would be problematic, a large number of casualties would be placed
OCR for page 275
BURN AND BLAST CASUALTIES: TRIAGEIN NUCLEAR WAR
275
in the expectant category. A In serial treatment, the physician would move
from one casualty to the next, spending whatever time may be necessary
to stabilize or support the patient. This strategy might well result in the
pnys~c~an railing to see or treat some of the most severely injured; yet
these, even if seen, might present problems too complex for resolution in
this context.
. . . ~ .,.
Every square mile (about 2.62 km2) of this triage area in New York
City would contain 12,274 injured people. Statistically, there would be
one casualty every 19-20 yards (about 17-18 m). The majority of the
casualties would have sustained first- and second-degree burns of the upper
body, covering less than 20 percent of their body surface area, fractures
of the upper limbs and torso, contusions and lacerations of all kinds, and
head and face injuries. They might well be mobile and would constitute
the population that would flock to sites of care. Approximately 37 percent
of those who would be injured in the 12-15-km zone, or 296,000 people,
would be severely injured (see Table 3~. Some of these people would be
trapped in collapsed buildings, pinned under heavy wreckage, and unable
to move on their own. Their injuries would include blunt and penetrating
chest and abdominal trauma, major long-bone and pelvic fractures with
significant hemorrhage, and extensive second- and third-degree burns.
Even under the best of circumstances, for people with these injuries to
survive, they would have to be found, assessed, and treated within 6 to
8 hours.
In the first 2 days, each physician might be able to encounter 72 cas-
ualties, but, in these postattack conditions, advanced intervention would
be very difficult to carry out or sustain. The situation would present two
insuperable obstacles: no transport or access to the victims and scarce
resources. The skills and experience of the teams that assembled would
be relatively random. It is likely that no power or water would be available
for the first several days. Equipment and supplies would be limited to
what remained on site at standing health facilities. Extncating victims is
a time-consuming and arduous task: it took several heavy construction
cranes, 10 hydraulic rescue tools, and scores of fire department members
and emergency medical technicians a total of 13 hours to remove 301
people (113 of them dead) from the wreckage of the Hyatt Hotel in Kansas
City in 1981. ~ ~ ~ Transporting these severely injured from where they were
found to a site of care might prove impossible. Treating these patients
would require intravenous fluids, blood transfusions, intravenous anti-
biotics, airway resuscitation and maintenance, debridement and excision
of contaminated wounds, fracture stabilization, and operative intervention
for those with penetrating injuries or ongoing internal bleeding. Unless
circumstances permitted an intense and focused allocation of medical
OCR for page 276
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OCR for page 277
BURN AND BLAST CASUALTIES: TRIAGE IN NUCLEAR WAR
277
resources on systems of support and intervention, the mortality rate among
these severely injured would approach 100 percent within 2 days.
The majority of the injured (assumed here to be the thousands who fled
the 10-12-km zone and those in the 12-15-km zone) would confront a
much lower ongoing mortality rate, due primarily to hypovolemia from
dehydration or hemorrhage, the effects of exposure and exhaustion, and
the impact of infection. In the 1-Mt scenario for one city, radiation would
not be a significant factor, but the medical care available to these survivors
might well not match the resources marshalled by the Japanese in the
early postattack period.
The pattern of medical management this data base implies mirrors what
took place during the U.S. Civil War, in which those listed as wounded
were those who had survived the privation of days of lying in fields before
being picked up or, for the bulk of them, those who had walked to sites
of care. Whether or not these reference case casualties would survive their
injuries would depend, as it did in the U.S. Civil War, on whatever food
and water could be obtained, the subsequent risk of infection in an ef-
fectively preantibiotic era, and the local incidence of disease. Mortality
rates among those hospitalized in the U. S. Civil War were approximately
14 percent; it is unlikely that the prevailing rate for the moderately and
mildly injured survivors of a nuclear war could be less. A most conser-
vative estimate of early mortality among each group of 72 initial survivors
thus approximates 100 percent for all severely injured and 14 percent for
all others, resulting, among those not killed outright at the time of the
bombing, in an overall death rate, 20 days later, of 46 percent, or 33 of
every 72 injured.
This figure results from what might grimly be termed best case analysis,
in which the population casualty rates are the lowest of all instances
prepared in the 100-Mt urban reference attack, in which systematic re~-
version to an austere triage posture is assumed and in which the care of
the moderately injured is estimated to be in accord with the hospital
experience of the U.S. Civil War.
A number of assumptions were made in evaluating the New York City
1-Mt nuclear attack example; these assumptions will certainly not hold in
progressively more comprehensive reference cases.
1. All surviving physicians were assumed to possess some knowledge
of acute care medicine, to behave professionally, and to maintain a triage
discipline not previously demanded of any U.S. physician, civilian or
member of the military. The inadequacy of this assumption is profound.
The disaster of nuclear war, even as narrowly defined as it is in this
reference case, would create an enormous stress on those attempting to
function in the role of health care provider. The literature on coping
OCR for page 278
278
HEALTH CONSEQUENCES OF NUCLEAR WAR
behavior among disaster victims does not support facile assumptions in
this regard. Pushed to his limits, Sasaki, a physician in Hiroshima,
roamed among the injured aimlessly "wiping, daubing, winding, wiping,
daubing, winding.''ll3 Behavior in the postattack world may well reach
extremes of fragmentation, terror, and involution we have not yet seen. ~4
Nothing in the training of a physician confers protection against the psy-
chological ravages of this environment.
2. Those with moderate and minor injuries were assumed to suffer the
same mortality rates as hospitalized casualties in the U.S. Civil War, a
cohort composed predominantly of patients with blast injuries, subject to
high rates of infection and disease, yet of young and vigorous constitution
and sustained by a system of medical supply and nursing care incomparably
superior to that which the injured survivors of nuclear war would face.
There is no basis, aside from common sense, for extrapolating a higher
mortality rate: data from later wars increase the disparity in support system
comparability; data from earlier wars or disasters yield less reliable in-
formation on early and delayed mortality. As an underestimate, it con-
tributes a cautious level of magnitude to the dimensions of mass casualty
management in this circumstance.
3. By limiting the discussion to the 100-Mt airburst reference case, the
factor of radioactive fallout was excluded. In the more extensive cases,
involving surface as well as air explosions, radiation injury would con-
tribute seriously to all subsequent mortality rates for those injured by burn
and blast. Estimates of excess mortality in this setting of mixed trauma
might serve to increase to 50 percent the proportion of those classified as
severely injured (and thus expected to die) and might well double the 14
percent mortality rate among those with moderate and minor injuries.
CONCLUSION
The methodical approach to such dimensions is to recognize the limits
of possible intervention. Modern triage protocols apply to conditions in
which the mix of transport and resource availability allows physicians to
make early headway against the high mortality of the severely injured.
From World War I on, the knowledge that complex support delivered
within a matter of hours could save lives once thought lost has driven the
development and design of the response to mass casualties. If it is ac-
knowledged at the outset that no galvanization of effort can contribute to
the salvage of the severely injured, the problem becomes less complex.
The choices then revolve around how much time and material should be
expended on humanitarian support of those who are probably going to die
and how much should be devoted to the care of those with moderate
OCR for page 279
BURN AND BLAST CASUALTIES: TRIAGE IN NUCLEAR WAR
279
injuries who might live. Those with minor injures, in this setting, could
not receive care.
The reference case employed here, and all those developed by Daugherty
et al.,~°5 refrain from a discussion of a massive nuclear war. Population
losses in such a catastrophe lie outside our experience and defy the human
and technological systems we have so far devised to attempt to mitigate
disaster and alleviate suffering. On the global scale of nuclear war, as
described in the scenario of Harwell and Grover,~is people would face a
picture of such devastation and death that the concept of mass casualty
management loses all meaning. Historically, such medical management
has constituted a highly complex human enterprise. In the bleakness of a
post-war world, virtually every survivor would be a casualty, and social
organization could well prove unsustainable. Mass casualty medicine,
crafted and practiced in war, is a product of He process that may eventually
drive it, and everything we know, into oblivion.
ACKNOWLEDGMENT
The author would like to thank Robert Mascola for his contribution as
research assistant in the preparation of this paper.
NOTES
The Shorter Oxford English Dictionary, Third Edition, Vol. 2. Pp. 2358, 2375. Oxford:
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Mosby.
Richardson, R. G. 1974. Larrey: Surgeon to Napoleon's Guard. Pp. 1-6, 158-168.
London: John Murray.
3Tuttle, A. D. 1927. Handbook for the Medical Soldier. Pp. 84-85. New York: William
Wood and Co.
4Keegan, J. 1976. The Face of Battle. Pp. 267-269. New York: Viking Press.
sU.S. Armed Forces. 1958. Emergency War Surgery, NATO Handbook, Pp. 163-173.
Washington, D.C.: U.S. Department of Defense, U.S. Government Printing Office.
6Baker, S. P., B. O'Neill, W. Haddon, Jr., and W. B. Long. 1974. The injury severity
score: A method for describing patients with multiple injuries and evaluating emergency
care. J. Trauma 14:187-196;Ebskov, B. 1981. Initialhospitalcareof the multitraumatized
patient. Ann. Chir. Gyn. 70:233-236; Melsom, M. A., M. D. Farrar, and R. C. Vowers.
1975. Battle casualties. Ann. R. Coll. Surg. 56:289-303; Ryan, J. M. 1984. The Falklands
War Triage. Ann. R. Coll. Surg. 66:195-196.
7Cowley, R. A., ed. 1982. Mass Casualties: A Lessons Learned Approach. Pp. 141-
145. Washington, D.C.: U.S. Department of Transportation, U.S. Government Printing
Office.
~Goldwyn, M., and V. W. Sidel. 1968. The Physician and War. Pp. 325-346 in E. F.
Torrey, ea., Ethical Decisions in Medicine. Boston: Little, Brown.
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280
HEALTH CONSEQUENCES OF NUCLEAR WAR
9Zawacki, B. E. 1985. ICU physician's ethical role in distributing scarce resources.
Crit. Care Med. 13:57-60.
Morton, J. H., L. M. Cramer, and S. I. Schwartz. 1964. Emergency management of
a major civilian disaster. Arch. Surg. 89: 105-113.
~Yates, D. W. 1979. Major disasters: Surgical triage. Br. J. Hosp. Med. 22(4):323-
328.
Winslow, G. R. 1982. Triage and Justice. Pp. 1-23. Berkeley, Calif.: University of
California Press.
3Ziperman, H. H. 1959. Sorting for Disaster Survival. J. Am. Med. Assoc. 171:202.
~4Straub, P. F. 1912. Medical Service in Campaign: A Handbook for Medical Officers
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civilian hospital. Bull. Am. Coll. Surg. 4g:342-361.
~5Keegan, Face of Battle, pp. 112-113, 197-203; Winslow, Triage and Justice, pp. 1
3.
Richardson, Larrey, pp. 2-4.
Garrison, F. H. 1922. Notes on the History of Military Medicine. Pp. 5, 41-46, 84-
95, 133-134. Washington, D.C.: Association of Military Surgeons.
brooks, S. 1966. Civil War Medicine. Pp. 50-62. Springfield, Ill.: Charles C Thomas;
Woodham-Smith, C. 1960. The Reason Why. Pp. 258-271. New York: E. P. Dutton.
DUES. Army. 1959. Medical Service Theater of Operations, Field Manual FM8-10. P.
17. Washington, D.C.: Department of the Army. As cited in Goldwyn and Sidel, Ethical
Decisions, p. 346.
20Fulton, J. F. 1953. Medicine, warfare, and history. J. Am. Med. Assoc. 153:482-
488.
Churchill, E. D. 1972. Surgeon to Soldiers: Diary and Records of the Surgical Con-
sultant, Allied Force Headquarters, World War II. P. 89. Philadelphia: J. B. Lippincott.
22Goldwyn and Sidel, Ethical Decisions, pp. 335-336.
23World Medical Association. 1956. Code of Ethics in Wartime. World Medical As-
sociation: New York. As cited in Goldwyn and Sidel, Ethical Decisions, p. 346.
24O'Donnell, T. J. 1960. The morality of triage. Georgetown Med. Bull. 14:68-71.
2sU.S. Armed Forces, Emergency War Surgery, pp. 1-6.
26Ibid., p. 7.
27Brooks, Civil War Medicine, pp. 3-40; Cunningham, H. H. 1968. Field Medical
Services at the Battles of Manassas. Pp. 1-22. Athens, Gal: University of Georgia Press.
28Fuller, J. F. C. 1961. The Conduct of War 1789-1961. Pp. 105-106. London: Me-
thuen; Millis, W. 1956. Arms and Men. Pp. 114-116. New York: New American Library.
29Cunningham, Field Medical Services, p. 61,90.
30Maxwell, W. Q. 1956. Lincoln's Fifth Wheel: The Political History of the United
States Sanitary Commission. Pp. 70-92. New York: Longmans, Green; Brooks, Civil War
Medicine, pp. 36-37.
brooks, Civil War Medicine, pp. 22-40; Cunningham, Field Medical Services, pp.
1-41.
32Adams, G. W. 1952. Doctors in Blue: The Medical History of the Union Army in the
Civil War. Pp. 67-70. New York: Henry Schuman.
33Ibid., pp. 1 12- 129
34Diffenbough, W. G.1965. Military surgery in the Civil War. Military Med. 130:492-
493.
35Ibid., p. 493.
36Brooks, Civil War Medicine, pp. 1-10.
OCR for page 281
BURN AND BLAST CASUALTIES: TRIAGE IN NUCLEAR WAR
281
37Commager, H. S., ed. 1950. The Blue and the Gray. New York: Bobbs-Merrill.
38Ibid., p. 769; Steiner, P. E. 1968. Disease in the Civil War. Pp. 3-45. Springfield,
Ill.: Charles C Thomas.
39Diffenbough, Military Surgery, pp. 491-492.
40Ibid., p. 492.
4iAdams, Doctors in Blue, pp. 130-173; Brooks, Civil War Medicine, pp. 106-121.
42Wallace, C., and J. Fraser. 1918. Surgery at a Casualty Clearing Station. Pp. 1-6.
London: A.&C. Black.
43Millis, Arms and Men, p. 185; Fuller, Conduct of War, pp. 134-45, 166-67, 171.
44Keegan, Face of Battle, p. 255.
45Fuller, Conduct of War, p. 135.
46Wallace and Fraser, Casualty Clearing Station, p. 2.
47Ibid., pp. 1-320
48Churchill, Surgeon to Soldiers, pp. 272-274.
49Ibid.
50Keegan, Face of BaKle, p. 268.
Willis, Arms and Men, pp. 252-254.
s2Ibid.
53Beebe, G. W., and M. E. DeBakey. 1952. Battle Casualties: Incidence, Mortality and
Logistic Considerations. Pp. 74-147. Springfield, Ill.: Charles C Thomas.
54Churchill, Surgeon to Soldiers, pp. 12-25, 36-70, 456-466, 475; Simeone, F. A.
1984. Studies of trauma and shock in man: William S. Stone's role in the military effort.
J. Trauma 24:281-287.
55Neel, S. 1973. Medical Support of the U.S. Army in Vietnam 1965-1970. P. 59.
Washington, D.C.: Department of the Army; Whelan, T. J., Jr., W. E. Burkhalter, and
A. Gomez. 1968. Management of war wounds. Adv. Surg. 3:338-349.
56Neel, Medical Support, pp. 59-79.
57Ibid., pp. 49, 53.
58Bellamy, R. F. 1984. The causes of death in conventional land warfare: Implications
for combat casualty care research. Military Med. 148:55-62.
59Neel, Medical Support, p. 119.
60Neel, Medical Support, pp. 46-58; Whelan et al., Management of war wounds, Adv.
Surg., pp. 229-257.
6~Neel, Medical Support, pp. 50-51.
62Keegan, Face of Battle, pp. 269-270.
63Neel, Medical Support, p. 52.
64Ibid.
6sDepartment of Defense. 1976. In Connection with the Conflict in Vietnam, fact sheet
January 1976, Washington, D.C.: U.S. Government Printing Off~ce. As cited in G. Emer-
son. 1976. Winners and Losers. Pp. 58-59. New York: Harcourt Brace Jovanovich.
66Rund and Rausch, Triage, pp. 3- 10.
67U.S. Armed Forces, Emergency War Surgery, pp. 172-173; Department of the Army.
1973. NATO Handbook on the Medical Aspects of NBC Defensive Operations, AMedP-
6. Pp. 6-1-6-11. Washington, D.C.: Department of the Army.
68Glasstone, S., and P. J. Dolan. 1977. The Effects of Nuclear Weapons. Pp. 80-86,
132-153. Washington, D.C.: U.S. Department of Defense, U. S. Government Printing
Office; Cooper, J., R. L. Maynard, N. L. Cross, and J. F. Hill. 1983. Casualties from
terrorist bombings. J. Trauma 23:955-967; Stapczynski, J. S. 1982. Blast injuries. Ann.
Emerg. Med. 11:687-694.
69Glasstone and Dolan, Nuclear Weapons, pp. 548-559.
OCR for page 282
282
HEALTH CONSEQUENCES OF NUCLEAR WAR
70Cooper, Terrorist Bombings, p. 959.
7iKennedy, T. L., and G. W. Johnston. 1975. Civilian bomb injuries. Br. Med. J. Vol.
I, February 15, p 383.
72Glasstone and Dolan, Nuclear Weapons, pp. 553-557, 175- 189.
73Keegan, Face of Battle, p. 264.
74Cooper, G. J., B. P. Pearce, M. C. Stainer, and R. L. Maynard. 1982. The biome-
chanical response of the thorax to nonpenetrating impact with particular reference to cardiac
injuries. J. Trauma 22:994-1008.
75Coppel, D. L. 1976. Blast injuries of the lungs. Br. J. Surg. 63:735-737.
76Cooper, Terrorist Bombings, p. 961.
77Ibid; Glasstone and Dolan, Nuclear Weapons, p. 552.
78Blocker, V., and T. G. Blocker, Jr. 1949. The Texas City disaster: A survey of 3000
casualties. Am. J. Surg. 78:756-771.
79Cooper, Terrorist Bombings, pp. 960-961.
8°Blocker and Blocker, Texas City Disaster, pp. 756-771.
Kennedy and Johnston, Civilian Bomb Injuries, p. 382; Stapczynski, Blast Injuries,
p. 690.
82Cooper, Terrorist Bombings, pp. 955-967.
83Ibid., pp. 959-960; Kennedy and Johnston, Civilian Bomb Injuries, pp. 382-383.
84Cooper, Terrorist Bombings, pp. 959-961.
85Blocker and Blocker, Texas City Disaster, pp. 756-771.
86Coppel, Blast Injuries of the Lungs, pp. 735-736.
87Kennedy and Johnston, Civilian Bomb Injuries, p. 383.
88Rodgers, H. W., and J. D. A. Robb. 1973. Surgery of civil violence. Pp. 321-331
in Selwyn Taylor, ea., Recent Advances in Surgery, no. 8, Edinburgh: Churchill Living-
stone.
89Glasstone and Dolan, Nuclear Weapons, p. 566.
90Constable, J. D. 1982. Burn injuries among survivors. Pp. 202-210 in E. Chivian et
al., eds., Last Aid. San Francisco: W. H. Freeman.
9iCooper, Terrorist Bombings, pp. 961-962; Glasstone and Dolan, Nuclear Weapons,
pp. 568-570; Committee for the Compilation of Materials. 1981. Hiroshima and Nagasaki.
Pp. 118-121. New York: Basic Books.
92Glasstone and Dolan, Nuclear Weapons, pp. 563-565.
93Glasstone and Dolan, Nuclear Weapons, pp. 568-574; Constable, Burn Injuries among
Survivors, pp. 202-210.
94Beecher, H. K. 1943. Resuscitation and sedation of patients with burns which include
the airway. Ann. Surg. 117:825-833; Churchill, Surgeon to Soldiers, pp. 12-25.
95Dimick, A. R. 1981. Triage of Burn Patients. Pp. 17-20 in Thermal Injuries, Topics
in Emergency Medicine. Gaithersburg, Md.: Aspen Systems Corp.; Glasstone and Dolan,
Nuclear Weapons, pp. 558-559; Committee for the Compilation of Materials, Hiroshima
and Nagasaki, pp. 120-121.
96Constable, Burn Injuries among Survivors, pp. 202-210.
97Artz, C. P., and D. R. Yarbrough III. 1972. Burns. Pp. 272-293 in D. C. Sabiston,
Jr., ea., Textbook of Surgery. Philadelphia: W. B. Saunders.
98Daugherty, W., B. Levi, and F. von Hippel. 1986. Casualties Due to the Blast, Heat,
and Radioactive Fallout from Various Hypothetical Nuclear Attacks on the U.S. This
volume.
99Oughterson, A. W., and S. Warren. 1956. Medical Effects of the Atomic Bomb in
Japan. Pp. 6-8, 90-93, 437-443. New York: McGraw-Hill.
~°°Committee for the Compilation of Materials, Hiroshima and Nagasaki, p. 523.
OCR for page 283
BURN AND BLAST CASUALTIES: TRIAGE IN NUCLEAR WAR
283
0lCommittee for the Compilation of Materials, Hiroshima and Nagasaki, pp. 107-114.
Committee for the Compilation of Materials, Hiroshima and Nagasaki, pp. 503-510.
Rund and Rausch, Triage, pp. 84-96.
4Committee for the Compilation of Materials, Hiroshima and Nagasaki, pp. 107-114.
05Daugherty et al. This volume.
106Postol, T. A. 1986. Possible fatalities from superfires following nuclear attacks in or
near urban areas. This volume.
107Abrams, H. L. 1984. Medical resources after nuclear war. J. Am. Med. Assoc. 252:653-
658.
l08These assumptions overstate the number available by (a) ignoring the probability that
the physicians might be more densely settled in the central areas of the cities, and (b) by
not accounting for injuries among those physicians in the 12-15 km area. This latter effect
is somewhat offset by assuming that all physicians among the injured who fled the 10-12
km zone would be considered in the category of casualty and not provider.
i09Diffenbough, Military Surgery, pp. 490-491.
ii°Sheedy, J. A. 1962. The role of forward medical support in handling masses of cas-
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Representative terms from entire chapter:
civil war
