Nationwide Response Issues After an Improvised Nuclear Device Attack: Medical and Public Health Considerations for Neighboring Jurisdictions: Workshop Summary (2014)

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7 Monitoring and Mass Care in Outlying Communities Key Points Made by Individual Speakers x Population monitoring and screening for radioactive contamination after an improvised nuclear device (IND) attack are highly labor-intensive. The functions can be carried out by volunteer radiation professionals who are trained and registered. Thousands of radiation professionals are found in each state, and hundreds have already been trained. x No coordinated, national systems are in place to track movement of evacuees, unify families, account for patients, and report the missing and the dead. An IND incident would result in nationwide displacement of patients and families. x Surge capacity, beyond what is available at hospitals, could be sup- plied by alternate care facilities for patients whose injuries are not seri- ous enough to warrant hospitalization. x It is vital to improve personal and family preparedness, which is currently extremely low. Socializing preparedness decreases dependency on resource-strapped public services and improves chances of survival. Communities both close to and far from the detonation will see a large influx of evacuees who may or may not have been exposed to dan- gerous radiation. By setting up reception centers with screening and monitoring activities, communities can better triage incoming patients and victims to the appropriate care and more quickly integrate needy pa- tients into national transport systems or the Radiation Injury Treatment Network (RITN) for specialized treatment. Reception centers are scala- ble and modular, said Armin Ansari of the Centers for Disease Control and Prevention (CDC). Communities can build flexibly on the core cen- ter functions—monitoring, screening, and decontamination—by adding 57 

58 NATIONWIDE RESPONSE ISSUES AFTER AN IND ATTACK such services as behavioral health care and advanced biodosimetry, de- pending on resources available. The speakers following Ansari gave oth- er examples of planning approaches and resources that could be used to build up a community’s capacity to respond to this type of event. THE NEED FOR RECEPTION CENTERS AND POPULATION MONITORING The goals of population monitoring, according to Ansari, are to build on the existing capabilities of mass care and public sheltering to assess evacuees’ medical needs related to a radiological emergency. Compo- nents might include delivering first aid, determining radiation exposure, screening for radioactive contamination, performing decontamination, and establishing an exposure registry. These reception centers will have similar components whether just outside of the disaster or hundreds of miles away. Daniel Weisdorf, executive committee member of RITN, described in greater detail the specific medical needs of victims that might present at a reception center. In contrast to the therapeutic radia- tion used in medicine, radiation from an improvised nuclear device (IND), radiological dispersal device, or nuclear plant incident may have these differentiating features: high dose rate, mixed isotope exposure, accompanying trauma or burns, and variable partial body shielding. With partial body shielding, the patient may not require treatment because the preserved marrow will repopulate, enabling blood counts to recover. Af- ter radiation exposure significant enough to produce acute radiation syn- drome, the hematopoietic system, as assessed by lymphocyte depletion kinetics, is one of the first systems to be affected, and the need for ongo- ing screening and monitoring of victims is warranted. As previously discussed, patients with injury to the hematopoietic system will need cytokine treatment, which will not be readily available in large amounts at typical community hospitals. Weisdorf explained that a smaller percentage of patients will warrant bone marrow transplants, depending upon the dose of radiation, the rate of lymphocyte depletion, the volume of body exposed, other injuries, and the number of other cas- ualties competing for bone marrow (which is a scarce resource). These patients will need to be transported to more specialized medical centers that are capable of providing this treatment. Community Reception Cen- ters with population screening and monitoring functions can triage in- coming victims to see what types of treatment are needed and determine 

MONITORING AND MASS CARE IN OUTLYING COMMUNITIES 59 priority. Generally speaking, patients exposed to less than 3 Gray (Gy) will recover with medical support; if exposure is 4–10 Gy, more medical care is warranted, and if exposures exceed 10 Gy, the patient is unlikely to recover. How Many Patients Are Expected? Based on modeling by the U.S. Defense Threat Reduction Agency, estimates indicate that a 10-kiloton (kt) IND detonated in a city of 2 mil- lion would produce more than13,000 immediate fatalities, 300,000 peo- ple who need medical care, and another 600,000 who need ambulatory or epidemiologic monitoring (see Table 7-1). The dose an individual was exposed to can be estimated from the individual’s location with respect to ground zero or the dangerous fallout kone along with time to vomit- ing. Although these indicators are imprecise, a failure to display gastro- intestinal symptoms implies that the radiation dose was low. For those patients not displaying gastrointestinal or other severe symptoms, moni- toring would continue over a period of days or weeks to make sure con- ditions do not deteriorate. This level of care could take place at a community hospital or alternate care sites and would likely not warrant transport to specialized hospitals or cytokine treatment. It is important to take into account the many victims who would need psychological moni- toring after the incident, even if they were not exposed to any radiation. This care could also occur at a reception center or community hospitals and will be covered in more detail in Chapter 8. TABLE 7-1 Estimated Number of Irradiation Casualties Patients, n 1-kiloton 10-kiloton Patient Category Radiation Dose, Gy Detonation Detonation Combined injuries All doses 1,000–3,000 15,000–24,000 (minimal to intensive care) Immediate All doses >7,000 >13,000 fatalities 

60 NATIONWIDE RESPONSE ISSUES AFTER AN IND ATTACK Patients, n 1-kiloton 10-kiloton Patient Category Radiation Dose, Gy Detonation Detonation Radiation fallout Expectant care >10 18,000 45,000 Intensive care 5–10 19,500 79,400 Critical care 3–5 33,000 108,900 Normal care 1–3 66,000 70,000 Ambulatory 0.5–1 82,500 139,000 monitoring Epidemiologic 0.25–0.5 106,000 147,000 monitoring Monitoring for <0.25 >150,000 >270,000 psychosocial well-being with- out other injury NOTE: The table depicts projected casualty estimates based on a 1- or 10-kt detonation. Assumptions include a city with a population of 2 million people and casualties estimated on the basis of the Hazard Prediction Assessment Ca- pability Program, version 3.21 (Defense Threat Reduction Agency, Fort Belvoir, Virginia). Combined injuries consist of radiation injuries in addition to burns or blunt trauma. SOURCE: Waselenko et al., 2004. BUILDING CAPACITY FOR COMMUNITY RECEPTION CENTERS Ansari described one tool recently developed by the CDC to guide local public health planners, a virtual community reception center (CRC).1 It is a CD-ROM that graphically illustrates population monitor- ing through a simulated three-dimensional environment and can give planners in cities and towns an idea of how to model existing shelter plans to adapt to the need for a CRC following an IND attack. After 1 See http://www.bt.cdc.gov/radiation/crc/vcrc.asp (accessed July 11, 2013). 

MONITORING AND MASS CARE IN OUTLYING COMMUNITIES 61 many years of developing shelter plans for natural disasters, community planners nationwide are familiar with the core functions of staffing and running an emergency shelter. Because many features of a community reception center will be similar to those of a shelter, various participants recommended starting with plans already in place. Building on this exist- ing “all-hazards” capacity and adding functions specific to a radiologic emergency can give local and state authorities confidence and progress in IND attack planning without the frustrations of starting from the beginning. Population Monitoring: Resources and Personnel To conduct population monitoring at a CRC requires a large cadre of trained staff. John Williamson of the Florida Department of Health esti- mated, using CDC simulation software, that 200 to 300 trained staff would be needed to screen 1,000 people per hour. To meet the demand, during the past 3 years his department has recruited and trained 640 vol- unteers. The volunteers are from his state’s Medical Reserve Corps, and they participated in a course on radiation and emergency medicine— training that was paid for with CDC grant funds. An underlying goal of the training was to demystify the science and to help professionals over- come misplaced fears about radiation exposure. An additional 342 Medi- cal Reserve Corps members participated in a 1.5-day course developed by the Oak Ridge Institute of Science and Education and held at various sites across Florida. An additional 50 Medical Reserve Corps volunteers were sent to Oak Ridge, Tennessee, to attend a full-scale radiation emer- gency course. Seeking additional personnel, Williamson’s department turned to its own ranks of environmental health strike teams. These multidisciplinary teams, with a total of 150 members, are distributed across the state of Florida and are trained to respond to hurricanes and other types of emer- gencies. His department added a radiation training course so that the teams could also be equipped to respond to a radiation emergency. Establishing a CRC requires not only trained staff, but also radiation detection equipment. With funding from the Department of Homeland Security (DHS), the Florida Department of Health purchased 200 instru- ment kits (portable dosimeters of several types), 40 digital ratemeters, 22 walk-through portal monitors, and 20 beta air particulate monitors. These instruments, plus 500 other sensors, are being used at numerous sites throughout the state. In the event of a radiation emergency, the instru- 

62 NATIONWIDE RESPONSE ISSUES AFTER AN IND ATTACK ments could be deployed at CRCs, public shelters, and hospitals to en- sure that the facilities are not being contaminated. The instruments re- quire calibration and repair, which is handled by Florida’s Bureau of Radiation Control. The funding for that in-house calibration unit comes in part from fees collected from Florida’s three major nuclear power sta- tions and radioactive materials licensees. Promoting the Use of Volunteers for Population Monitoring The recruitment and training of volunteer radiation professionals to conduct population monitoring in the event of an IND or other radiologi- cal emergency is the focus of a cooperative agreement between the CDC and the Conference of Radiation Control Program Directors (CRCPD), according to Ruth McBurney, the group’s executive director. CRCPD is a national organization of program directors, mostly from state and local agencies, who regulate the use of radioactive material, X-ray machines, and nuclear medicine and who oversee emergency planning for radiolog- ical events. The agreement with the CDC began as a pilot program in five states (including Florida) and one city2 to incorporate radiation pro- fessionals into the Medical Reserve Corps (McBurney, 2012). There is a large pool of radiation professionals from which to draw volunteers. For example, in one state alone, Florida, there are 25,000 radiation profes- sionals. Radiation professionals include medical physicists, health physicists, nuclear medicine technologists, X-ray technologists, radiation therapy technologists, and radiation professionals who work at nuclear power plants. Each of the pilot program’s states entered into a contract with CRCPD to recruit, manage, and train the volunteers through the vehicle of the Medical Reserve Corps. Each state developed a publishable plan for effective deployment and utilization of the volunteers and developed an action plan for continued and expanded use of the program. Altogeth- er, 275 to 300 volunteers were recruited and trained during the first year of the program. Several lessons emerged from the pilot project. One was the need for improved communications between CRCPD and the Medical Reserve Corps. Consequently, CRCPD’s working group overseeing the program brought in a liaison officer from the Medical Reserve Corps. Another 2 Florida, Kansas, New York City, North Carolina, Ohio, and Oregon. 

MONITORING AND MASS CARE IN OUTLYING COMMUNITIES 63 lesson was the need for long-term funding mechanisms to ensure contin- ued training and drills to keep the volunteers engaged. Finally, a need was shown for specific instructions for dealing with internal contamina- tion, which occurs after inhalation, ingestion, or transdermal absorption of radioactive materials. With support from the CDC, the CRCPD pro- gram was expanded to an additional 10 states and localities in 2012, and further expansion is expected in 2013. Practicing Community Reception Center Operations Thomas Langer of the Kansas Department of Health and Environ- ment described an exercise held in his state to simulate the detonation of two dirty bombs. The foremost goal of the exercise was to establish a community reception center for population monitoring, decontamination, and registration of citizens. The exercise, called Amber Waves, was jointly sponsored by his department and Wyandotte County, Kansas. In the scenario the bombs were simultaneously deto- “It’s important for us, and we realize that as well. It’s not about just what happens in nated in front of the local my community; it’s what happens in yours. fire department at the time It’s going to be a national response.” of a shift transfer. The hy- —Thomas Langer pothetical blasts succeeded in knocking out two shifts of first responders as well as their equipment. Langer said that the focus of the exercise was especially on the first 48 hours—a crucial time before the expected arrival of substantial state and federal resources. The exercise proved highly successful for one specific goal: to demonstrate that the newly formed Kansas Radiation Response Volun- teer Corps could effectively handle population monitoring. This volun- teer group, drawn from the ranks of Kansas’s radiation health care workers, was set up with the backing of the CDC and CRCPD. The exer- cise also successfully tested the integration of the Kansas State Animal Response Team, a new group that screens and decontaminates pets, into the CRC. That group was set up because of experiences from Hurricane Katrina, which revealed that people would not leave their homes if they could not take their pets. Although the CRC was set up in an armory, a future goal is to set up the CRC next to a hospital. There, the CRC staff would be in a better position to conduct triage and deter the “worried well” from entering the 

64 NATIONWIDE RESPONSE ISSUES AFTER AN IND ATTACK hospital. To counter low levels of preparedness in the population, Langer proposed holding a Radiation Preparedness Day, which would be a statewide drill similar to that held by Kansas for tornado preparedness and would make radiation a more familiar hazard for people. FAMILY ASSISTANCE IN OUTLYING COMMUNITIES Families will be devastated after an IND attack, according to Onora Lien of the Northwest Healthcare Response Network. For incidents of this magnitude, she said, there are no coordinated national systems in place to track movement of evacuees, unify families, account for pa- tients, and report the missing and the dead. There is also nothing in place to systematically deal with the psychological burden of survivors. Family assistance centers (FACs) could carry out many of these functions, she said. The concept of using an FAC after mass casualties traces back to the 1990s, when the military and the National Transportation Safety Board established FACs as a focal point for information and services geared for families of crash victims. Some of the functions of an FAC after an IND attack could be Web-based, Lien said, while others could be carried out in dedicated physical space. FACs can also be organized to deliver social and psychological ser- vices to those dealing with highly traumatic events and traumatic grief, to provide appropriate triage and referral to services, and to carry out case management. FACs also could deliver assistance to crime victims (funds for victims distributed by the Department of Justice). Lien suggested that FACs should try to integrate with already operational CRCs wherev- er possible, but some situations may call for a separate location depend- ing on what services are offered and the population. She urged the creation of a model FAC that applies not only to IND attacks, but also to all hazards. Lien posed a number of questions that could be used when establish- ing the protocols that will be used by FACs, and she emphasized the need for political support and direction to sustain this planning. Her questions related to three different issues: x Missing persons: What systems need to be established to cen- tralize information? Who will be responsible? How will local law enforcement coordinate with any efforts? How will the Red Cross’s Safe and Well program interface with any efforts? (Safe 

MONITORING AND MASS CARE IN OUTLYING COMMUNITIES 65 and Well is a Red Cross–run website for displaced persons to self-identify and to search for family members.) Who will be re- sponsible for unaccompanied minors? x Antemortem data collection: What is required for scientific identification? Where should antemortem data be collected, such as through a centralized victim identification center and call cen- ter? What are the best ways to coordinate with local law en- forcement or medical examiners? What about fatalities not occurring at the incident site? x Patient tracking: Can a system be centralized? How would such a system interface with the Joint Patient Assessment and Track- ing System, which is a patient tracking system expressly for the subgroup of patients being treated by the National Disaster Med- ical System? Who is responsible for communicating with fami- lies about patients’ status and whereabouts? What is the role for Department of Health and Human Services (HHS) service access teams3 and the Red Cross? One of the workshop participants said that centralized tracking of pa- tients could be done using barcodes and smartphone technologies, refer- encing a system used in a radiological dispersal device drill performed in Israel. The technology would allow the medical record to accompany the patient, but this has yet to be implemented and tested here. NATIONAL NETWORKS TO ASSIST IN VICTIM TRANSPORT AND CARE As mentioned previously, this type of incident would overwhelm local and even regional health care systems and would also demand very specialized treatment. To enhance a response with needs going beyond local health care, national transport systems and health networks could be used, decreasing the burden on systems in close proximity to the det- onation site and giving victims more access to needed beds and treat- ment. Daniel Weisdorf of the Radiation Injury Treatment Network (RITN) explained that RITN’s purpose is to provide surge capacity and management guidance for radiation casualties with bone marrow sup- pression. RITN’s nationwide network consists of 51 academic medical 3 See http://ccrf.hhs.gov/ccrf/FactSheets/SAT_Fact_Sheet_FINAL.pdf (accessed De- cember 11, 2013). 

66 NATIONWIDE RESPONSE ISSUES AFTER AN IND ATTACK centers, 6 blood donor centers, and 7 umbilical cord blood blanks. It re- ceives funding from the U.S. Office of Naval Research and coordinates with the Office of the Assistant Secretary for Preparedness and Response (ASPR). In the event of an IND attack, the network would take casualties with bone marrow suppression after they were triaged near the site of detonation. Patients would need to be accompanied by their earliest blood count results before being transported to a receiving hospital with- in RITN. Once patients are admitted, RITN has established guidelines for how they should be treated for acute radiation syndrome (RITN, 2010). De- pending upon their level of exposure, patients can be given blood trans- fusions, antibiotics, intravenous fluids, cytokines, and marrow trans- plantation. RITN has the capacity to conduct human leukocyte antigen (HLA) typing for 6,000 to 10,000 people per week, making it much more capable of handling large numbers of this type of patient than any typical community hospital. HLA typing is essential for matching patients to donor bone marrow for the purpose of transplantation. According to RITN’s annual tabletop exercise, its centers can handle up to 30,000 ir- radiated casualties (or approximately 550 patients for each of the 51 treatment centers), Weisdorf said. RITN has an established plan for the stockpiling of medications and constantly rotates products from stock- piles into clinical pharmacies in order to avoid expiration. The system is designed for managing medications in a cost-effective manner and for having them strategically located for immediate need, making RITN per- fectly poised as an able partner in the specialized response that would follow an IND incident. National Disaster Medical System Andrew Garrett of ASPR gave an overview of the National Disaster Medical System (NDMS), which is an ASPR-led collaborative partner- ship among HHS, the Department of Veterans Affairs (VA), the Depart- ment of Defense (DOD), and DHS. Its threefold mission is medical response, patient evacuation, and definitive care, i.e., care in a hospital or clinic after someone has been evacuated. NDMS supplements state and local resources and assists with surges of military casualties. For exam- ple, it recently served in the wake of Hurricane Sandy, in which 1,800 of its personnel logged 9,000 patient encounters. This system can signifi- cantly augment the health care resources at a disaster site, in part by team 

MONITORING AND MASS CARE IN OUTLYING COMMUNITIES 67 members working side by side with local clinical staff at any of 1,500 hospitals nationwide that have memoranda of understanding with NDMS. One of the greatest challenges after an IND attack will be the coordi- nation of medical and nonmedical information regarding all phases of care. Scant compatibility currently exists, as there is no unified data sys- tem. ASPR does have patient tracking ability through the Joint Patient Assessment and Tracking System (JPATS), but gaps in local system in- tegration and system complications keep JPATS from being an easy so- lution. However, work is continuing in this area and standards for an easily integrated and operated national system are envisioned. Another challenge Garrett described is the wide range of acuity—or the level of severity of injuries—after an IND incident. Furthermore, the acuity will evolve over time depending upon the amount of exposure to radiation. It may be difficult to predict future acuity and the need for transport based on initial presentation. Ongoing assessments and care requirements may change over the days to weeks after an IND attack. Complicating this issue is the fact that the type of care that is needed may not be feasible at the hospitals under agreement with NDMS. Currently, NDMS and RITN are not coordinated, so NDMS is considering some kind of formal relationship with RITN that would increase NDMS’s ca- pacity for handling specialty irradiated patients. All of these challenges could also represent opportunities for innovative solutions. Patients may be moved by air, ambulance, trains, buses, or specially configured semi- trailers, both via official transit and unofficial ad hoc methods. Yet another barrier stems from the fact that an IND incident does not respect geographic boundaries and jurisdictions. Even if there is a re- gional system of care, its capabilities will be overwhelmed by an IND attack. One regional care system will have to be coordinated with other regional care systems, and sharing laboratory results and other types of medical information among these systems will be very difficult, as will coordinating transport between systems. Garrett concluded his presenta- tion by observing that an IND attack imposes such a staggering threat that it is likely to overwhelm the community approach envisioned by the DHS’s National Response Framework. The circumstances may call for the federal government to lead the response, and NDMS could be another asset called in to assist. During the discussion, Garrett emphasized prioritizing short-term needs, because of the known scarcity of resources that government and responders will have at their disposal to respond to an incident of this 

68 NATIONWIDE RESPONSE ISSUES AFTER AN IND ATTACK magnitude. Improving the level of personal and family preparedness is becoming more and more necessary because current levels have been stagnant and federal funds for these activities are continuing to decline. In response to Hurricane Sandy, the shelves of stores were quickly emp- tied. People should have items stored away for a disaster instead of pan- icking at the last minute. Garrett explained that preparedness needs to become a social norm to adequately prepare communities. “Socializing” the concept of preparedness so that it permeates many parts of people’s lives can dramatically decrease dependency on public services after an incident that are guaranteed to be in short supply and can improve indi- vidual chances of survival in any disaster. Shortfalls in Military Patient Transport Donald Donahue of the American Board of Disaster Medicine fo- cused his presentation on the shortfalls in staging, transport, and receiv- ing of patients that is done through the DOD’s role within NDMS. Staging refers to movement of patients to the site of evacuation. The United States has a total of 55 disaster medical assistance teams, which working together could handle only about 5,000 patients per day. Mili- tary assets are not positioned for a timely response. An IND detonation in a major city would produce tens of thousands to hundreds of thou- sands of casualties who would need to be staged and transported, and Donahue highlighted some of the areas needing improvement. Clearly, the demand would outstrip supply. In terms of transport, there are limitations in personnel and equip- ment. The trained aeromedical personnel that would be needed to transport patients are limited in number. Most military aeromedical per- sonnel (65 percent) are in the Air Force Reserve. It will take time to mo- bilize them in a time of crisis. For critical care patients not only is there a limited number of highly trained personnel, but each three-member criti- cal care air transport team can accommodate only three ventilator pa- tients or six non-ventilator critical care patients per flight. Furthermore, the aircraft that would be used for transporting the patients are in short supply. There are only 1,000 cargo planes in the U.S. Air Force, Air Force Reserve, and Air National Guard that could be reconfigured for medical transportation. The U.S. Transportation Command has been complaining about a shortage of airlift capability since 2001, Donohue said. In addition to cargo planes there are 1,400 airframes, including 45 

MONITORING AND MASS CARE IN OUTLYING COMMUNITIES 69 Boeing 767s, identified for potential use in aeromedical evacuation that could be configured for a response. They are available to the federal government on short notice from the Civil Reserve Air Fleet (CRAF), a program developed decades ago to offer surge capacity for the military in a national emergency. But CRAF is not as capable of a rapid response as IND event consequences would demand. The rate-limiting factor is that it takes 60 hours to reconfigure each plane, and there is only one contrac- tor that can perform the reconfigurations. Challenges in Medical Surge Nationally Shortfalls will abound at receiving hospitals as well, Donahue said. In the decade since the September 11, 2011, terrorist attacks, about 12 percent of hospital beds have been eliminated. From 1995 to 2001, 20 percent of intensive care unit capacity was eliminated. And between 1990 and 2009 the number of emergency rooms in non-rural hospitals declined by 27 percent. The lack of surge capacity and hospital beds means that local hospitals and health care centers will be unable to han- dle an influx of 100 patients needing advanced medical care. No city in America and no geographic region could handle 1,000 patients suddenly needing advanced medical care, according to a Senate report (U.S. Sen- ate Committee on Government Affairs, 2001). Currently, most hospitals are on the razor’s edge of staffing to the extent that, even if beds were available, there might not be sufficient clinical staff. Another problem Donahue highlighted is coordination among networks, saying that a sur- vey by the VA found that one-quarter of its hospitals did not even know that they were part of the NDMS. Donohue concluded his presentation by observing that there are serious deficiencies in patient movement planning and a corresponding shortfall in receiving hospital capacity. He advised thinking outside the box for better coordination and planning. In the ensuing discussion, Donahue and Lien expressed skepticism about the estimated number of hospital beds that could be used for surge capacity. They both said they believe that hospitals may be overstating their surge capacity. Lien said that additional surge capacity could be available at long-term and other alternate-care facilities and that this should be pursued as an opportunity for increasing capacity. NDMS could partner with long-term care facili- ties, behavioral health centers, and other types of health care centers to accept patients whose health care needs do not fully justify hospitaliza- 

70 NATIONWIDE RESPONSE ISSUES AFTER AN IND ATTACK tion but who need more advanced care than shelters and community re- ception centers can provide (see Chapter 9). SUMMARY After an IND blast, outlying communities will be reeling from the number of evacuees. With a 10-kt device detonated in a city of 2 million, 300,000 will need medical care, and 600,000 will need to be monitored. The goals of population monitoring are to assess evacuees’ medical needs, deliver first aid, determine radiation exposure, screen for radioac- tive contamination, perform decontamination, and establish an exposure registry. These functions, which are to be carried out at community re- ception centers, are labor-intensive. One solution to this problem of re- sources is to recruit volunteers from the ranks of radiation professionals and train and register them. This is the intent of a recently developed program by the Conference of Radiation Control Program Directors with support from the CDC. The program has already trained hundreds of volunteers and continues to expand. To meet the high demand for formal medical treatment, outlying communities can draw on RITN, which can provide care to some 30,000 radiation casualties with bone marrow suppression, who will generally require a very specialized treatment. Another source of medical surge resources is NDMS, which has around 8,000 volunteers, 5,000 of whom are credentialed clinicians. NDMS can deliver care in a field clinic or hospital, provide evacuation and track patient movement, and deliver definitive care through a network of 1,500 hospitals. However, obtaining patient transportation to sites of medical care is likely to be a problem. There are currently serious deficiencies in patient movement planning, particularly with aeromedical evacuation. The military transports are nei- ther properly equipped nor positioned for a timely response, but with better coordination and interagency communication, this situation could be greatly improved.