Open Access Open Access  Restricted Access Subscription or Fee Access

The impact of radiation dread on mass casualty medical management during a radiological or nuclear event

Mary Sproull, Naoru Koizumi, PhD, Emanuel Petricoin, PhD, Gregory D. Koblentz, PhD, William G. Kennedy, PhD


Since the events of 9/11, a concerted interagency effort has been undertaken to create comprehensive emergency planning and preparedness strategies for management of a radiological or nuclear event in the US. These planning guides include protective action guidelines, medical countermeasure recommendations, and systems for diagnosing and triaging radiation injury. Yet, key areas such as perception of risk from radiation exposure by first responders have not been addressed. In this article, we identify the need to model and develop new strategies for the medical management of large-scale population exposures to radiation, examine the phenomena of radiation dread and its role in emergency response, and review recent findings on the willingness to work of first responders and other personnel involved in mass casualty medical management during a radiological or nuclear event.


radiation dread, nuclear, mass casualty management, first responder, emergency planning

Full Text:



Bui E, Joseph B, Rhee P, et al.: Contemporary management of radiation exposure and injury. J Trauma Acute Care Surg. 2014; 77(3): 495-500.

Singh VK, Romaine PLP, Seed TM: Medical countermeasures for radiation exposure and related injuries: Characterization of medicines, FDA-approval status and inclusion into the strategic national stockpile. Health Phys. 2015; 108(6): 607-630.

Turner JA, Rebmann T, Loux TM, et al.: Willingness to respond to radiological disasters among first responders in St. Louis, Missouri. Health Secur. 2020; 18(4): 318-328.

Balicer RD, Catlett CL, Barnett DJ, et al.: Characterizing hospital workers’ willingness to respond to a radiological event. PLoS One. 2011; 6(10): e25327.

Barnett DJ, Thompson CB, Errett NA, et al.: Determinants of emergency response willingness in the local public health workforce by jurisdictional and scenario patterns: A cross-sectional survey. BMC Public Health. 2012; 12(1): 164.

Errett NA, Barnett DJ, Thompson CB, et al.: Assessment of medical reserve corps volunteers’ emergency response willingness using a threat- and efficacy-based model. Biosecur Bioterror. 2013; 11(1): 29-40.

Buddemeier B, Dillon M: Key Response Planning Factors for the Aftermath of Nuclear Terrorism. Livermore, CA: Lawrence Livermore National Laboratory, 2009. LLNL-TR-410067.

National Security Staff Interagency Policy Coordination Subcommittee for Preparedness & Response to Radiological and Nuclear Threats: Planning Guidance for Response to a Nuclear Detonation. 2010. Available at Accessed June 14, 2021.

US Department of Homeland Security: Nuclear/Radiological Incident Annex to the Response and Recovery Federal Interagency Operational Plans. 2016. Available at Accessed June 14, 2021.

US Department of Homeland Security: Radiological Dispersal Device (RDD) Response Guidance: Planning for the First 100 Minutes. 2017. Available at Accessed June 14, 2021.

National Alliance for Radiation Readiness (NARR). 2018. Available at Accessed September 2019.

NARR Clearinghouse: National Alliance for Radiation Readiness. Available at Accessed September 2019.

National Association of County & City Health Officials (NACCHO): Preparedness brief. Available at Accessed September 2019.

Centers for Disease Control and Prevention: Radiation Emergencies. 2018. Available at Accessed September 2019.

US Department of Health & Human Services: Radiation Emergency Medical Management (REMM). 2018. Available at Accessed September 2019.

Sproull MT, Camphausen KA, Koblentz GD: Biodosimetry: A future tool for medical management of radiological emergencies. Health Secur. 2017; 15(6): 599-610.

Ramesh AC, Kumar S: Triage, monitoring, and treatment of mass casualty events involving chemical, biological, radiological, or nuclear agents. J Pharm Bioall Sci. 2010; 2(3): 239-247.

Lerner EB, Cone DC, Weinstein ES, et al.: Mass casualty triage: An evaluation of the science and refinement of a national guideline. Disaster Med Public Health Prep. 2011; 5(2): 129-137.

Lansdowne K, Scully CG, Galeotti L, et al.: Recent advances in medical device triage technologies for chemical, biological, radiological, and nuclear events. Prehosp Disaster Med. 2015; 30(3): 320-323.

Cibulsky SM, Sokolowski D, Lafontaine M, et al.: Mass casualty decontamination in a chemical or radiological/nuclear incident with external contamination: Guiding principles and research needs. PLoS Curr. 2015; 7. DOI: 10.1371/currents.dis.9489f4c319d9105dd0f1435ca182eaa9.

Mettler FA Jr: Medical resources and requirements for responding to radiological terrorism. Health Phys. 2005; 89(5): 488-493.

Cone DC, Koenig KL: Mass casualty triage in the chemical, biological, radiological, or nuclear environment. Eur J Emerg Med. 2005; 12(6): 287-302.

Hrdina CM, Coleman CN, Bogucki S, et al.: The “RTR” medical response system for nuclear and radiological mass-casualty incidents: A functional TRiage-TReatment-TRansport medical response model. Prehosp Disaster Med. 2009; 24(3): 167-178.

Coleman CN, Koerner JF: Biodosimetry: Medicine, science, and systems to support the medical decision-maker following a large scale nuclear or radiation incident. Radiat Prot Dosim. 2016; 172(1-3): 38-46.

Coleman CN, Weinstock DM, Casagrande R, et al.: Triage and treatment tools for use in a scarce resources-crisis standards of care setting after a nuclear detonation. Disaster Med Public Health Prep. 2011; 5(Suppl. 1): S111-S121.

Hick JL, Bader JL, Coleman CN, et al.: Proposed “exposure and symptom triage” (EAST) tool to assess radiation exposure after a nuclear detonation. Disaster Med Public Health Prep. 2018; 12(3): 386-395.

Bushberg JT, Kroger LA, Hartman MB, et al.: Nuclear/radiological terrorism: Emergency department management of radiation casualties. J Emerg Med. 2007; 32(1): 71-85.

Berger ME, Leonard RB, Ricks RC: Hospital Triage in the First 24 Hours after a Nuclear or Radiological Disaster. Oak Ridge, TN: Oak Ridge Institute for Science and Education (ORISE), 2010.

Wolbarst AB, Wiley AL, Nemhauser JB, et al.: Medical response to a major radiologic emergency: A primer for medical and public health practitioners. Radiology. 2010; 254(3): 660-677.

Koenig KL, Goans RE, Hatchett RJ, et al.: Medical treatment of radiological casualties: Current concepts. Ann Emerg Med. 2005; 45(6): 643-652.

Murrain-Hill P, Coleman CN, Hick JL, et al.: Medical response to a nuclear detonation: Creating a playbook for state and local planners and responders. Disaster Med Public Health Prep. 2011; 5(S1): S89-S97.

Hick JL, Weinstock DM, Coleman CN, et al.: Health care system planning for and response to a nuclear detonation. Disaster Med Public Health Prep. 2011; 5(Suppl. 1): S73-S88.

Zahariev V, Hristov N: Diagnostic criteria for assessment by general practitioners of patients injured in radiation incidents and cases of radiological terrorism. Disaster Med Public Health Prep. 2018; 12(4): 507-512. DOI: 10.1017/dmp.2017.90.

Flynn DF, Goans RE: Nuclear terrorism: Triage and medical management of radiation and combined-injury casualties. Surg Clin North Am. 2006; 86(3): 601-636. Accessed September 2019.

Khripunov I: The social and psychological impact of radiological terrorism. Nonproliferation Rev. 2006; 13(2): 275-316.

Stone FP: The “Worried Well” Response to CBRN Events: Analysis and Solutions The Counterproliferation Papers Future Warfare Series No. 40. Alabama: USAF Counterproliferation Center, 2007.

Balog RP, Bacher R, Chang P, et al.: Development of a biodosimeter for radiation triage using novel blood protein biomarker panels in humans and non-human primates. Int J Radiat Biol. 2020; 96(1): 22-34. DOI: 10.1080/09553002.2018.1532611.

Homer MJ, Raulli R, DiCarlo-Cohen AL, et al.: United States Department of Health and Human Services biodosimetry and radiological/nuclear medical countermeasures programs. Radiat Prot Dosim. 2016; 171(1): 85-98.

BARDA Backs Biodosimetry Tests from MRIGlobal, DxTerity Diagnostics. 2016. Available at

Johnson M: BARDA-funded radiation exposure MDx test development continues apace. Genomeweb. 2018.

DiCarlo AL, Maher C, Hick JL, et al.: Radiation injury after a nuclear detonation: Medical consequences and the need for scarce resources allocation. Disaster Med Public Health Prep. 2011; 5(1): S32-S44.

Casagrande R, Wills N, Kramer E, et al.: Using the model of resource and time-based triage (MORTT) to guide scarce resource allocation in the aftermath of a nuclear detonation. Disaster Med Public Health Prep. 2011; 5(S1): S98-S110.

Knebel AR, Coleman CN, Cliffer KD, et al.: Allocation of scarce resources after a nuclear detonation: Setting the context. Disaster Med Public Health Prep. 2011; 5(Suppl. 1): S20-S31.

Caro JJ, DeRenzo EG, Coleman CN, et al.: Resource allocation after a nuclear detonation incident: Unaltered standards of ethical decision making. Disaster Med Public Health Prep. 2011; 5(Suppl. 1): S46-S53.

Coleman CN, Knebel AR, Hick JL, et al.: Scarce resources for nuclear detonation: Project overview and challenges. Disaster Med Public Health Prep. 2011; 5(Suppl. 1): S13-S19.

Sproull M, Camphausen K: State-of-the-art advances in radiation biodosimetry for mass casualty events involving radiation exposure. Radiat Res. 2016; 186(5): 423-435.

Singh VK, Romaine PL, Newman VL, et al.: Medical countermeasures for unwanted CBRN exposures: Part II radiological and nuclear threats with review of recent countermeasure patents. Expert Opin Ther Pat. 2016; 26(12): 1399-1408.

Blakely WF, Salter CA, Prasanna PG: Early-response biological dosimetry–recommended countermeasure enhancements for mass-casualty radiological incidents and terrorism. Health Phys. 2005; 89(5): 494-504.

Jarrett DG, Sedlak RG, Dickerson WE, et al.: Medical treatment of radiation injuries—Current US status. Radiat Meas. 2007; 42(6-7): 1063-1074.

Goans RE: Medical Management of Radiological Casualties. Bethesda, MD: Armed Forces Radiobiology Research Institute, 2013.

Dainiak N: Medical management of acute radiation syndrome and associated infections in a high-casualty incident. J Radiat Res. 2018; 59(Suppl_2): ii54-ii64.

Dainiak N, Berger P, Albanese J: Relevance and feasibility of multi-parameter assessment for management of mass casualties from a radiological event. Exp Hematol. 2007; 35(4 Suppl. 1): 17-23.

Etherington G, Rothkamm K, Shutt AL, et al.: Triage, monitoring and dose assessment for people exposed to ionising radiation following a malevolent act. Radiat Prot Dosim. 2011; 144(1-4): 534-539.

Blakely WF: Early Biodosimetry Response: Recommendations for Mass-Casualty Radiation Accidents and Terrorism. RC-12 Biological Dosimetry. Buenos Aires, Argentina: 12th International Congress of the International Radiation Protection Association. October 2008. Available at Accessed June 14, 2021.

Renn O: Perception of risks. Toxicol Lett. 2004; 149(1-3): 405-413.

Loewenstein GF, Weber EU, Hsee CK, et al.: Risk as feelings. Psychol Bull. 2001; 127(2): 267-286.

Ropeik D, Gray G: RISK: A Practical Guide for Deciding What’s Really Safe and What’s Really Dangerous in the World around You. Boston: Houghton Mifflin Company, 2002.

Brown TJ, Brennan MC, Li M, et al.: Association of the extent of resection with survival in glioblastoma: A systematic review and meta-analysis. JAMA Oncol. 2016; 2(11): 1460-1469.

Slovic P: The perception gap: Radiation and risk. Bull At Sci. 2012; 68(3): 67-75.

Erikson K: Radiation’s lingering dread. Bull At Sci. 1991; 47(2): 34-39.

Smith EC, Burkle FM Jr, Archer FL: Fear, familiarity, and the perception of risk: A quantitative analysis of disaster-specific concerns of paramedics. Disaster Med Public Health Prep. 2011; 5(1): 46-53.

Dallas CE: Medical lessons learned from chernobyl relative to nuclear detonations and failed nuclear reactors. Disaster Med Public Health Prep. 2012; 6(4): 330-334.

Dallas CE: Medical training for nuclear and radiological events: The “atomic age” returns. Disaster Med Public Health Prep. 2013; 7(5): 441-442.

DeJesus IT: Three Mile Island accident and the enduring questions of ties to cancer and deaths. Pennsylvania Real-Time News [Internet]. March 31, 2019. Available at Accessed September

Revkin AC: The ‘Dread to Risk’ ratio on radiation and other discontents. The New York Times. March 23, 2011.

Becker SM: Communicating risk to the public after radiological incidents. BMJ. 2007; 335(7630): 1106-1107.

Becker SM, Middleton SA: Improving hospital preparedness for radiological terrorism: Perspectives from emergency department physicians and nurses. Disaster Med Public Health Prep. 2008; 2(3): 174-184.

Johnson JH, Zeigler DJ: Distinguishing human responses to radiological emergencies. Econ Geogr. 1983; 59(4): 386-402.

Sheikh S, McCormick LC, Pevear J, et al.: Radiological preparedness- awareness and attitudes: A cross-sectional survey of emergency medicine residents and physicians at three academic institutions in the United States. Clin Toxicol (Phila). 2012; 50(1): 34-38.

Pearce JM, Rubin GJ, Selke P, et al.: Communicating with the public following radiological terrorism: Results from a series of focus groups and national surveys in Britain and Germany. Prehosp Disaster Med. 2013; 28(2): 110-119.

Bass SB, Gordon TF, Maurer L, et al.: How do low-literacy populations perceive “dirty bombs”? Implications for preparedness messages. Health Secur. 2016; 14(5): 331-344.

Akabayashi A, Takimoto Y, Hayashi Y: Physician obligation to provide care during disasters: Should physicians have been required to go to Fukushima? J Med Ethics. 2012; 38(11): 697-698.

Macfarlane A: Radiation and regulation in a Post-Fukushima world. Health Phys. 2016; 110(2): 118-122.

Bass SB, Greener JR, Ruggieri D, et al.: Attitudes and perceptions of urban African Americans of a “dirty bomb” radiological terror event: Results of a qualitative study and implications for effective risk communication. Disaster Med Public Health Prep. 2015; 9(1): 9-18.

Shimura T, Yamaguchi I, Terada H, et al.: Public health activities for mitigation of radiation exposures and risk communication challenges after the Fukushima nuclear accident. J Radiat Res. 2015; 56(3): 422-429.

Miura M, Ono K, Yamauchi M, et al.: Perception of radiation risk by Japanese radiation specialists evaluated as a safe dose before the Fukushima nuclear accident. Health Phys. 2016; 110(6): 558-562.

Becker SM: Addressing the psychosocial and communication challenges posed by radiological/nuclear terrorism: Key developments since NCRP report no. 138. Health Phys. 2005; 89(5): 521-530.

Rogers MB, Amlot R, Rubin GJ: The impact of communication materials on public responses to a radiological dispersal device (RDD) attack. Biosecur Bioterror. 2013; 11(1): 49-58.

Radiation Hazard Scale: Centers for Disease Control and Prevention. Available at Accessed September 2019.

Amri R: Yes, bananas are radioactive, and yes, you should keep eating them anyway. Forbes. October 18, 2016.

Reicher S, Podpadec T, Macnaghten P, et al.: Taking the dread out of radiation? Consequences of and arguments over the inclusion of radiation from nuclear power production in the category of the natural. J Environ Psychol. 1993; 13(2): 93-109.

Ropeik D: The dangers of radiophobia. Bull At Sci. 2016; 72(5): 311-317.

Bromet EJ: Emotional consequences of nuclear power plant disasters. Health Phys. 2014; 106(2): 206-210.

Pastel RH: Radiophobia: Long-term psychological consequences of chernobyl. Mil Med. 2002; 167(Suppl. 1): 134-136.

Havenaar J, Rumyantzeva G, Kasyanenko A, et al.: Health effects of the chernobyl disaster: Illness or illness behavior? A comparative general health survey in two former soviet regions. Environ Health Perspect. 1997; 105(Suppl. 6): 1533-1537.

Irisawa A: The 2011 Great east Japan earthquake: A report of a regional hospital in Fukushima prefecture coping with the Fukushima nuclear disaster. Dig Endosc. 2012; 24(Suppl. 1): 3-7.

The National Academies of Sciences Engineering and Medicine: In Pray L, Kahn B, Wollek S (eds.): Exploring Medical and Public Health Preparedness for a Nuclear Incident Proceedings of a Workshop. Washington, DC: The National Academies Press, 2019.

Harmon K: Japan’s post-Fukushima earthquake health woes go beyond radiation effects. Naturecom. 2012.

Curado MP, Costa Neto SB: Psychosocial aspects of the victims of the accident with caesium-137 in Goiania (1987-1994). International Nuclear Information Systems. International Atomic Energy Agency, 244-248. Available at Accessed June 14, 2021.

Veenema TG, Lavin RP, Bender A, et al.: National nurse readiness for radiation emergencies and nuclear events: A systematic review of the literature. Nurs Outlook. 2019; 67(1): 54-88.

Stevens G, Jones A, Smith G, et al.: Determinants of paramedic response readiness for CBRNE threats. Biosecur Bioterror. 2010; 8(2): 193-202.

Sato Y, Hayashida N, Orita M, et al.: Factors associated with nurses’ intention to leave their jobs after the Fukushima Daiichi nuclear power plant accident. PLoS One. 2015; 10(3): e0122389.

Veenema TG, Walden B, Feinstein N, et al.: Factors affecting hospital- based nurses’ willingness to respond to a radiation emergency. Disaster Med Public Health Prep. 2008; 2(4): 224-229.

Markenson D, Woolf S, Redlener I, et al.: Disaster medicine and public health preparedness of health professions students: A multidisciplinary assessment of knowledge, confidence, and attitudes. Disaster Med Public Health Prep. 2013; 7(5): 499-506.

Rebmann T, Charney RL, Loux TM, et al.: Firefighters’ and emergency medical service personnel’s knowledge and training on radiation exposures and safety: Results from a survey. Health Secur. 2019; 17(5): 393-402.

Dallas CE, Klein KR, Lehman T, et al.: Readiness for radiological and nuclear events among. Front Public Health. 2017; 5: 202.

Kaiser HE, Barnett DJ, Hsu EB, et al.: Perspectives of future physicians on disaster medicine and public health preparedness: Challenges of building a capable and sustainable auxiliary medical workforce. Disaster Med Public Health Prep. 2009; 3(4): 210-216.

Case C, Coleman CN, Bader JL, et al.: Guidance, training and exercises for responding to an improvised nuclear device: First receivers, public health. Health Phys. 2018; 114(2): 165-172.

Cabrera SL, Beaton RD: The role of occupational health nurses in terrorist attacks employing radiological dispersal devices. AAOHN J. 2009; 57(3): 112-119; quiz 20-1.

Siegfried AL, Carbone EG, Meit MB, et al.: Identifying and prioritizing information needs and research priorities of public health emergency preparedness and response practitioners. Disaster Med Public Health Prep. 2017; 11(5): 552-561. DOI: 10.1017/dmp.2016.198.

Dynlacht JR, Zeman EM, Held KD, et al.: Education and training needs in the radiation sciences: Problems and potential solutions. Radiat Res. 2015; 184(5): 449-455.

Hotz ME, Fliedner TM, Meineke V: Radiation accident preparedness: A European approach to train physicians to manage mass radiation casualties. Health Phys. 2010; 98(6): 894-897.

DiMaggio C, Markenson D, Loo GT, et al.: The willingness of US emergency medical technicians to respond to terrorist incidents. Biosecur Bioterror. 2005; 3(4): 331-337.

Kobayashi L, Suner S, Shapiro MJ, et al.: Multipatient disaster scenario design using mixed modality medical simulation for the evaluation of civilian prehospital medical response: A dirty bomb case study. Simul Healthc. 2006; 1(2): 72-78.

Markenson D, Reilly MJ, DiMaggio C: Public health department training of emergency medical technicians for bioterrorism and public health emergencies: Results of a national assessment. J Public Health Manag Pract. 2005; 11(Suppl): S68-S74.

Qureshi K, Gershon RRM, Sherman MF, et al.: Health care workers’ ability and willingness to report to duty during catastrophic disasters. J Urban Health. 2005; 82(3): 378-388.

Reilly MJ, Markenson D, DiMaggio C: Comfort level of emergency medical service providers in responding to weapons of mass destruction events: Impact of training and equipment. Prehosp Disaster Med. 2007; 22(4): 297-303.

Shapira Y, Marganitt B, Roziner I, et al.: Willingness of staff to report to their hospital duties following an unconventional missile attack: A state-wide survey. Isr J Med Sci. 1991; 27(11-12): 704-711.

Adams LM, Melius J: Prepared to respond? Exploring personal disaster preparedness and nursing staff response to disasters. Disaster Med Public Health Prep. 2020; 7: 1-6. DOI: 10.1017/dmp.2020.47.

Veenema TG, Moran TP, Kazzi Z, et al.: Radiation injury treatment network medical and nursing workforce radiation: Knowledge and attitude assessment. Disaster Med Public Health Prep. 2020; 22: 1-7. DOI: 10.1017/dmp.2020.253.

Ochi S, Tsubokura M, Kato S, et al.: Hospital staff shortage after the 2011 triple disaster in Fukushima, Japan-an earthquake, tsunamis, and nuclear power plant accident: A case of the soso district. PLoS One. 2016; 11(10): e0164952.

Skorga P, Persell DJ, Arangie P, et al.: Caring for victims of nuclear and radiological terrorism. Nurse Pract. 2003; 28(2): 24-43.

Veenema TG, Lavin RP, Schneider-Firestone S, et al.: National assessment of nursing schools and nurse educators readiness for radiation emergencies and nuclear events. Disaster Med Public Health Prep. 2019; 13(5-6): 936-945.

Ferguson RW, Barnett DJ, Kennedy RD, et al.: Prioritizing communication about radiation risk reduction in the United States: Results from a multi-criteria decision analysis. Disaster Med Public Health Prep. 2020; 23: 1-9. DOI: 10.1017/dmp.2020.89.

Koerner JF, Norman Coleman C, Murrain-Hill P, et al.: The medical decision model and decision maker tools for management of radiological and nuclear incidents. Health Phys. 2014; 106(6): 645-651.

Rose CM: Radiation scientists and homeland security. Radiat Res. 2002; 157(5): 607-609.

Berris T, Nusslin F, Meghzifene A, et al.: Nuclear and radiological emergencies: Building capacity in medical physics to support response. Phys Med. 2017; 42: 93-98.

Miller CW, Whitcomb RC Jr, Ansari A, et al.: The roles of medical health physicists in a medical radiation emergency. Health Phys. 2007; 93(5 Suppl.): S187-S190.

Irwin W: The ROSS: A radiological/nuclear subject matter expert filling a critical national need. Health Phys. 2018; 114(2): 141-147.

Ingram RJ: Emergency response to radiological releases: Have we communicated effectively to the first responder communities to prepare them to safely manage these incidents? Health Phys. 2018; 114(2): 208-213.

Ropeik D: Critical areas for improvement in communications regarding radiological terrorism. Health Phys. 2018; 114(2): 214-217.

Hyer RN: NCRP program area committee 7: Radiation education, risk communication, outreach, and policy. Health Phys. 2018; 114(2): 259-260.

Rubin GJ, Page L, Morgan O, et al.: Public information needs after the poisoning of Alexander Litvinenko with Polonium-210 in London: Cross sectional telephone survey and qualitative analysis. BMJ. 2007; 335(7630): 1143-

Coleman CN, Bader JL, Koerner JF, et al.: Chemical, biological, radiological. Disaster Med Public Health Prep. 2019; 13(5-6): 995-1010.



  • There are currently no refbacks.