Action before Nuclear Explosion
If there is sufficient warning in advance of an attack, head as quickly as possible for the best shelter available. This is the same procedure as would be used during an attack by ordinary, high-explosive bombs. At the sound of the alarm, get your protective mask ready. Proceed to your station or to a shelter, as ordered. If you are ordered to a shelter, remain there until the "all clear" signal is given.

In the absence of specially constructed shelters during a nuclear explosion ashore, you can get some protection in a foxhole, a dugout, or on the lowest floor or basement of a reinforced concrete or steel-framed building. Generally, the safest place is in the basement near walls. The next best place is on the lowest floor in an interior room, passageway, or hall, away from the windows and, if possible, near a supporting column. Avoid wooden buildings when possible. If you have no choice, take shelter under a table or bed rather than going out into the open. If you have time, draw the shades and blinds to keep out most of the heat from the blast. Only those people in the direct line of sight of thermal emission will be burn casualties; that is, anything that casts a shadow will afford protection. Tunnels, storm drains, and subways can also provide effective shelter.

In the event of a surprise attack, no matter where you are-out in the open on the deck of a ship, in a ship compartment, out in the open ashore, or inside a building-drop to a prone position in a doorway or against a bulkhead or wall. If you have a protective mask with you, put it on. Otherwise, hold or tie a handkerchief over your mouth and nose. Cover yourself with anything at hand, being especially sure to cover the exposed portions of the skin, such as the face, neck, and hands. If this can be done within a second of seeing the bright light of a nuclear explosion, some of the heat radiation may be avoided. Ducking under a table, desk, or bench indoors, or into a trench, ditch, or vehicle outdoors, with the face away from the light, will provide added protection.

Treatment of Nuclear Casualties
Most injuries resulting from the detonation of a nuclear device are likely to be mechanical wounds resulting from collapsing buildings and flying debris, and burns caused by heat and light liberated at the time of detonation.

Aburn is a burn, regardless of whether it is caused by a nuclear explosion or by napalm, and its management remains the same. This is also true of fractures, lacerations, mechanical injuries, and shock. In none of these is the treatment dictated by the cause. For most of the conventional injuries, standard first-aid procedures should be followed.

The following word of caution should be considered when you are treating wounds and burns: Dressings for wounds and burns should follow a closed-dressed principle, with application of an adequate sterile dressing using aseptic techniques. Make no attempt to close the wound, regardless of its size, unless authorized by a physician. If signs of infection and fever develop, give antibiotics. When a physician is not available to direct treatment, the Corpsman should select an antibiotic on the basis of availability and appropriateness, and administer three times the recommended amount. If the antibiotic does not control the fever, switch to another. If the fever recurs, switch to still another. Overwhelming infection can develop rapidly in the patients due to burns or damage from radiation. Whenever a broad-spectrum antibiotic is given, administer oral antifungal agents.

To date, there is no specific therapy for injuries produced by lethal or sublethal doses of ionizing radiation. This does not mean that all treatment is futile. Good nursing care and aseptic control of all procedures is a must. Casualties should get plenty of rest, light sedation if they are restless or anxious, and a bland, nonresidue diet.

DECONTAMINATION
If you suspect that you are contaminated, or if detection equipment indicates you are, report to a personnel decontamination facility as soon as possible.

Facilities
In a large-scale nuclear catastrophe, there may be numerous casualties suffering not only from mechanical injuries and thermal burns, but from radiation injuries and psychological reactions as well.

The medical facility should consist of a personnel monitoring station, both clean and contaminated emergency treatment stations, a decontamination station, a sorting station, and various treatment stations. It should be set up so that personnel must pass through a monitoring station prior to sorting for medical care. If there is a need for decontamination, the casualty should be routed through the decontamination station on the way to the sorting station. The physical layout should be arranged so that no casualty can bypass the monitoring station and go directly to a treatment station. Also, casualties who are contaminated should be unable to enter clean areas without first passing through a decontamination station. The medical facility flow chart shown in figure 8-3 illustrates an appropriate schema for handling those exposed to nuclear radiation.

TEAMS.-Patients brought in by the rescue teams or arriving on their own should first proceed through the monitoring station to determine whether or not they are contaminated with radioactive material. No medical treatment should be instituted in the monitoring station. Only personnel who have had training and experience as members of Radiological Safety/Decontamination teams or as members of Damage Control parties should be assigned to the monitoring station. Those operating the monitoring station should have a basic knowledge of and experience with radiac instruments. Of the personnel available to the treatment facility, several of those most experienced and knowledgeable in radiological safety and radiation protection should be assigned supervisory jobs in the decontamination station. Also, it is highly desirable to have some personnel with operating room experience to decontaminate patients with traumatic injuries. It is not necessary for the other personnel working in the decontamination station to have any appreciable training or experience other than that given when the medical facility is put into operation.

MONITORS.-After the patients are monitored, they are directed or taken down one of four avenues, depending upon their physical conditions. Those requiring immediate lifesaving measures should be considered contaminated and routed directly through the monitoring station to the contaminated emergency treatment station. Definitive monitoring for these individuals may be performed at the decontamination station. Both treatment stations are set up much the same and should have only those facilities necessary for immediate lifesaving forms of treatment. Personnel working in these stations should be better versed in emergency first-aid care than those used for monitoring and for rescue teams, but they need not be trained in radiation monitoring.

SORTING.-After emergency lifesaving procedures have been attended to, casualties from the clean emergency treatment station should be taken directly to the sorting station, and those from the contaminated treatment station should be taken to the decontamination station. Casualties not requiring immediate emergency treatment should be taken or sent from the monitoring station directly to the sorting station or to the decontamination station, whichever is appropriate. The decontamination station should be set up to take, hold, and dispose of all contaminated clothing and to supply clean replacement clothing after the casualty has been decontaminated. Monitoring equipment will also be required, as will showering and washing facilities, and some capability for surgical (e.g., wound) decontamination when necessary.

Cleaning
Early removal of radioactive "contamination" will reduce radiation burns, radiation dosage, and the chances of inhaling or ingesting radioactive material. There are two rules to be remembered in the removal of radioactive contamination:

Contamination is easily spread, so "spot" cleaning must be attended to before general decontamination procedures are started.
Removal of radioactive contamination is best accomplished with soap and water.

SPOT CLEANING.-Cotton swabs or gauze may be used to decontaminate moist areas. Use gummed tapes to decontaminate dry areas. If, after the first cleansing, decontamination is inadequate, the process should be repeated three to five times. If contamination persists, a preparation consisting of a mixture of 50 percent detergent and 50 percent cornmeal, with enough water added to make a paste, should be tried. The contaminated area should be scrubbed (preferably with a soft-bristle surgical brush) for 5 minutes, then rinsed.

GENERAL CLEANING.-After the hot spots have been removed, the second step is to shower with soap and water. Scrub the entire body, including the hair and nails. After the shower, monitor again; if any contamination remains, repeat spot cleaning and shower procedures. If the hair is contaminated, shampoo it several times. If it becomes apparent that shampooing has not removed the radioactive material, cut the hair as close to the scalp as necessary to remove the radioactive material.

If areas become tender from excessive washing, it may be necessary to restore some of the skin oils by gently rubbing in a small amount of lanolin or ordinary hand or face cream. This will soothe the skin and prepare it for further decontamination if additional steps are necessary. Decontamination should be continued until the radioactivity has been reduced to the "safe" level set by the responsible Medical Department representative. Wounds or body parts that resist decontamination may have to be covered and the patient referred to a higher-level medical treatment facility.

UNCONTAMINATED AREAS.-Protect any uncontaminated cut, scratch, or wound with an impermeable tape or other suitable material while decontaminating the rest of the body. If a wound is already contaminated, the simplest and least drastic decontamination method available should be tried first, always by trained medical personnel. First, the wound should be carefully bathed or flushed with sterile water, and a reasonable amount of bleeding should be encouraged. Following decontamination, standard triage procedures are used.

Additional information pertaining to the initial management of irradiated or radioactively contaminated individuals may be obtained from the current version of BUMEDINST 6470.10, Initial Management of Irradiated or Radioactively Contaminated Personnel.