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Chapter 2. Medical and tactical characteristics of damage sites

caused by urgent and exigent cases

In modern wars, mass destruction weapons are used along with ordinary
weapons. In case of war, medical system will function under very complex and
specific conditions. Therefore, to provide effective medical maintenance of
population medical staff shall have sufficient information about damaging factors
of mass destruction weapons, damage sites caused by these factors, medical and
tactical characteristics of arising mass damages.
Civil Defense (CD) heads of medical facilities, Civil Defense Medical Service
(CDMS) heads and command officers of medical agencies shall make decision on
the arrangement of medical maintenance of population in mass destruction sites.
To make correct decision they shall know how to assess the situation (general and
medical) established in emergency sites.
Situation means aggregate of emergency factors affecting CDMS's activity.
Assessment of the situation consists of the achievement a result based on the
analysis of factors positively and negatively affecting the activity of the medical
service in a certain situation.

Assessment of the established situation of the medical service allows to:

1. clarify the number of the injured;
2. accurately determine duties of the medical service, type and volume of the
medical aid;
3. determine the demand in the medical service forces and means;
4. Select more effective form of treatment and evacuation measures for
elimination of established sites of ES.

Mass destruction weapons (MDW) include nuclear, chemical and

bacteriologic (biologic) weapons.
Subject to the type of applied MDW mass destruction sites fall into 4 groups:
1) bacteriologic
2) chemical
3) nuclear
4) combined destruction sites.

Medical and tactical assessment of the situation established

in the bacteriologic (biologic) destruction site

Pathogenic microorganisms used for the contamination of human beings,

animals and plants, their toxins, as well as means of their delivery to the target are
called bacteriological weapons.
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This weapon uses bacteria and their toxins, viruses, rickettsiae, fungi etc.
This kind of weapon includes agents of plague, cholera, tularemia, smallpox,
anthrax, tetanus etc.

Bacteriological weapon is applied by several methods:

Bu using an aerosol, through infected insects and rodents;
through subversive actions (water and food);
toxic substances with bacterial toxins.

Bacteriological weapon has specific peculiarities:

1. High efficiency potential (capable of infecting human beings and animals
with small doses).
2. Latent stage.
3. Contagiosity (transmissibility from a sick to a healthy individual).
4. Long-term impact and resistance to environment.
5. Determination of difficulties in detection, relation to food environment and
resistance to antibiotics.
6. Large number of agents.
7. Strong psychological effect.
8. Low costs of preparation (as compared with nuclear and chemical
weapons).

The area where mass bacterial injuries of human beings, animals and plants
occurred as a result of the use of bacteriological (biological) weapon is called
biologic damage site.
Its sizes depend on the method of application and amount of microorganisms,
meteorological factors, ground relief, nature of constructions and design of
residential areas.
When bacteriological weapon is applied by aerosol spray, infectious diseases
acquire mass character. When applied by means of infected insects and rodents,
gradual increase of infectious diseases is observed.
A number of factors shall be considered in the assessment of the situation
established in the bacteriologic damage site:
type and method of application of applied infectious agents;
timely detection;
area of the contaminated zone and expected area of contamination;
meteorological situation;
season;
number and density of the population;
nature of constructions;
provision of population with protective equipment;
number of the vaccinated population;
provision of the population with non-specific and specific means of
prevention and treatment.
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Detailed analysis of the factors in the elimination of the site is of great

significance.
Calculation of expected medical losses in case of application of a
bacteriological weapon becomes complicated for several reasons.
First - agents of several infectious diseases may be applied at the same time.
Second - different resistance of different people to contagion and specific
features of each microorganism and virulence factor.
Third - increase of sanitary losses due to transmission (secondary) of the
disease from the sick to healthy individuals. This makes it possible to make
accurate calculation of sanitary losses.
According to specialists, 25-50% of the general number of the population may
initially become infected in the result of exposure to bacteriological means.
Preliminary preventive measures and application of personal protective measures
may significantly decrease contagion.

Medical and tactical characteristics of the chemical contamination site

Toxic substances of strong properties

Besides the nuclear weapon which is extremely dangerous for the life and
activity of people in the modern period, armies of some countries use also
chemical weapons.
Toxic substances (TS), means of their delivery (transportation) to the target
and application are called chemical weapons.
TS are compounds of high toxic influence. They are applied for chemical
contamination of people, animals and plants, as well as territories and facilities.
They are delivered to the target by means of rockets, aerosol generators,
aviation chemical bombs, projectiles, mines, grenades etc.
TS have very specific properties:
easily spread in environment;
continuous damaging effect;
diversity of the clinical picture and development dynamics of intoxication;
Partial penetration of TS into organism through respiratory, digestive and
transcutaneous ways;
dependence of development of intoxications on the ways of penetration of
TSs into organism;
psychoemotional effect;
necessity to use protective equipment.

There are several classifications of TSs developed based on different features.

Classification of TS based on leading clinical symptoms:
1. Nerve agents (organophosphorous substances- POS) - sarin, soman, Vx-
gases.
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2. Blood and nerve - cyanic acid, chlorine cyanide etc.

3. Asphyxiating - phosgene, diphosgene etc.
4. Skin-resorptive - yprite, lewisite etc.
5. Psychochemical (psychotomimetics) - "BZ", LSD etc.
6. Irritants - adamsite, chloracetophenone, chloropicrin etc.

Classification of TSs based on the impact

1. Killing TS - sarin, soman, Vx-gases etc.
2. Temporarily disabling TS - adamsite, chloropicrin, BZ, LSD etc.

Mass damage to people, animals and plants caused by the chemical weapon
and area seriously contaminated with toxic substances is called chemical
contamination site.
Sizes and nature of a chemical damage site depend on the type and method of
application of TS, ground relief, design of residential areas.
The situation caused by the use of the chemical weapon is called chemical
situation.
Assessment of the chemical situation consists of determination of the impact
of TSs on people, animals and plants, water sources and other facilities, choice of
the elimination measures most favorable for the activity of CD agencies and
population.
Assessment of the Civil Defense Medical Service (CDMS) facility's chemical
situation is attended by CD head of the facility, command officers of its
headquarters and CDMS agencies. The situation is assessed based on the chemical
survey data. Sometimes the assessment may be of forecasting nature.
Assessment of chemical situation shall be carried out based on the following
initial information:
1. Type and time of application of TS
2. Means of application of TS
3. Area of application of TS
4. Wind speed and direction
5. Air and soil temperature
Sanitary losses among the population present in the chemical damage site
may be up to 80-90%.

After the assessment of the chemical situation CDMS head and chief of
the staff:
inform CDMS agencies about the contamination of the area and air with
toxic substance;
analyse and make conclusions regarding the working ability of population
and agencies for the elimination of chemical damage sites;
determine the most suitable activity options;
select safer regions for the accommodation of the population and agencies;
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determine the time within which it is necessary for people to remain in

protective equipment;
determine the rules of sanitary cleansing of people contaminated with TS
and decontamination of machinery.

CDTS agencies' staff shall perform the following in chemical damage site:
1. chemical and medical survey;
2. first medical aid to the injured and their evacuation from the site;
3. sanitary cleansing of persons contaminated with TS;
4. decontamination of the used machinery, property, as well as clothes of the
injured for medical purposes and other works.

Medical and tactical assessment of the nuclear contamination site

Ordnance having damaging nuclear energy impact in the result of nuclear

explosion reaction is called nuclear weapon.
Explosive power of a nuclear weapon is characterized with trinitrotoluene-
equivalent. Trinitrotoluene-equivalent is a measure of energy release expressed as
amount of trinitrotoluol which in case of explosion releases equal amount of
energy. Power of various nuclear ordinances is usually up to several million tons
(megaton). Nuclear explosion differs from ordinary ammunition both by the power
of the damaging impact, and harmful impact of various factors. For the first time
nuclear weapon was used by US armed forces in August, 1945 in Hiroshima and
Nagasaki cities of Japan. To deliver a nuclear weapon to the target, various types
of rockets, airplanes, submarine vessels, ships, as well as artillery tubes may be
used. Depending on the purpose of use of a nuclear weapon and nature of the
target of attack, nuclear ammunition may be exploded in space, air, on the ground
and under the ground, on the water and under the water. Nuclear explosion may
result in the appearance of five kinds of harmful impacts. These are called
damaging factors of nuclear explosion. The factors are the following:
1. blast wave,
2. light radiation,
3. penetrating radiation (ionizing rays),
4. radioactive contamination of land
5. electromagnetic impulse.
About 50% of the nuclear explosion energy is spent to blast wave, 35% to
light radiation, 10% to radioactive contamination of land, and 1% to the creation of
electromagnetic impulse. Now, let's have a look at the damaging factors of a
nuclear weapon.

1. Blast wave
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Blast wave consists of severely compressed and heated air flow spreading to
all directions at a speed higher that sound speed. Its destructive and damaging
force consists of excessive pressure and air speed impulse. They depend on the
weight of an explosive substance, center of explosion, distance to a man (facility)
and duration of impact.
Excessive pressure is a difference between normal atmospheric pressure and
maximum pressure on the front surface of a blast wave.
Blast wave is measures in kilopascals (kPa) and kilogram-force per 1cm2
(kg/cm2). It may damage unprotected population both directly, and indirectly - with
secondary items (structures of destroying constructions and plants, brick, concrete,
glass fragments etc). In the result of impact of a blast wave on human organism
various contusions, bruises, damages of hearing organs, nasal and ear
hemorrhages, bone fractures, dislocations, multiple traumas, internal injuries may
occur.
When the excessive pressure on the front surface of the blast wave is higher
than 100 kPa air temperature reaches 3500S. This leads to burns of open surfaces of
the body and upper respiratory tract.
Population using protective equipment may get injured by the blast wave
(damages of hearing organs, nasal and ear hemorrhages etc.).
Special plants, basements and ground relief may be used for the protection
from the blast wave.

2. Light radiation
Light radiation is a strong visible ultraviolet and infrared radiation emitted by
a fireball appearing in case of nuclear explosion. Duration of the impact may be
10-20 seconds subject to the nuclear load force. Damaging impact of light radiation
depend on light impulse, i.e. amount of light energy per each square centimeter of
the surface located vertically in relation to light rays. Unit of measure of the light
impulse is taken as Cal/m2 (calories per 1 cm2) or kJ/m2 (kiloJoule per 1 m2).
kJ/m2=0.239 cal/cm2, 1 cal/cm2 =40 kJ/m2.
The amount of light impulse forming in different areas depends of the force,
type of nuclear explosion, distance an air conditions. Despite shortness of the
impact, at long distances light radiation may cause body burns, temporary or
permanent blindness, flaming, carbonization and fusing of different materials, fires
in residential areas, forests, mines. E.g. in case of 1 mln tons force nuclear
explosion 4cal/cm2 light impulse is present at 19 km, 10 cal/cm2 at 15 km, 16
cal/cm2 at 10 km distance, which leads to mild, medium and severe burns of open
surfaces of body.
Burns are divided into 4 groups by the degree of severity: 1st degree burns
(2-5 cal/cm2), 2nd degree burns (5-10 cal/cm2), 3rd degree burns (10-15 cal/cm2)
and 4th degree burns (more than 15 cal/cm2).
Light radiation does not pass through non-transparent materials (wall, wood,
building etc.). Light radiation may cause strong fires in residential areas, woods,
fields.
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Impact of light radiation depends greatly on meteorological conditions. Thick

fog, rain and snow reduce its impact by 10-20 times. Asylums and shelters are the
safest places for the protection from light radiation.

3. Penetrating radiation (ionizing rays)

Penetrating radiation consists of invisible gamma rays and neutrons spreading
around the explosion site in case of nuclear explosion.
Impact of penetrating radiation is assessed as a swallowed dose and measured
in Grays (Gr), Roentgen (R), and rad units of measurement. 1 Roentgen is a dose
of gamma rays in the result of which at 0 decree temperature and 760 mm of
mercury pressure about 2 billion pairs of ions form in 1cm 3 of air.
In case of nuclear explosion, penetrating radiation lasts only 10-25 seconds
considering the gamma radiation in its content. Within this short period,
unprotected people and animals may get radiation injury.
Impact of penetrating radiation consists of the fact that gamma rays and
neutrons ionize molecules of live tissues. This leads to metabolic disturbance,
change in the life of cells and various members, weakening of resistance of the
organism to infectious diseases. Person exposed to radiation does not feel it. Signs
of damage appear after a certain period, course of disease depends on the dose of
radiation.
Radiation disease has 4 degrees of severity:
I degree (mild degree) severe radiation disease develops when the organism
is exposed to 1-2 Gr (100-200 rd), II degree (medium degree of severity) severe
radiation disease develops when the organism is exposed to 2-4 Gr (200-400 rd),
III degree (severe) acute radiation disease 4-6 Gr (400-600 rd), IV degree (very
severe) acute radiation disease 6 Gr (600 rd) at a time.
Clinical course of acute radiation disease is divided into 4 periods:
1. Period of initial reactions - appear in several minutes or hours.
2. Latent period - appear within 1-6 days.
3. Acute period.
4. Convalescence period - with complex treatment or bone marrow
transplantation, positive results may be expected.

Impact of penetrating radiation attenuates when passes through close and

thick materials. E.g. 2.7 cm thick steel, 10 cm thick concrete, 14 cm thick soil, 23
cm thick of water, 30 cm thick wood attenuates penetrating radiation 2 times (these
are called semi-attenuation layer). Protection from penetrating radiation is based
exactly on this property of materials. Thus, dose of radiation is attenuated 40 times
by a covered trench, and 400 times by a basement accommodated for protection.

4. Radioactive contamination of ground

In the first moments after the emergence of ground-based nuclear explosion
fireball contains radioactive particles. Fireball is covered with smoke and vapour,
rises up and turns into heaps of clouds. Air flows raise dust and dirt from the
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ground and take it together with radioactive cloud. Large radioactive dust particles
fall directly to the area of explosion. Remaining parts remain in the cloud and are
taken from the center of explosion to hundreds of kilometers away.
Degree of radioactive contamination (RC) depends on the type and force of
explosion, period after explosion, distance to the center of explosion,
meteorological conditions and ground relief. The area exposed to radioactive
contamination looks like an ellipse. Radioactive contamination field is usually
divided into 4 zones by the contamination force:
- very dangerous,
- dangerous,
- strong,
- mild (weak) contamination (pollution) zones.
Degree of contamination of an area is characterized by the level (i.e. force) of
radiation and measured in roentgens per hour (R/hour). If in a certain place dose
power of ionizing rays is 0.5 R/hour or more, the area is is considered to be
contaminated with RS. Thus, labor activity in the area is prohibited.
Radioactive substances (RS) have no external characteristics (color, smell
etc.). Contamination may be detected only by using special dosimetric devices.
Damaging impact of RS is connected with 2 factors (external impact of
gamma rays on the organism and contact of beta-particles with skin and organism).
The factors influence the skin and lead to acute radiation disease. High density of
the substance contacting with skin may cause burns. They enter body with food,
water and air, absorb into blood stream and spread into organs and tissues by blood
circulation.
A part of radioactive isotopes (cesium, tellurium, molybdenum) spread
equally in tissues and quickly withdraw from organism, however others
accumulate in certain organs and tissues. Thus, iodine isotopes accumulate in
thyroid gland, strontium and barium in bone tissues, tellurium and molybdenum in
liver.
Not all the organs are equally sensitive to RS. Most critical organs are divided
into 3 groups by sensitivity (its radiation may be harmful to organism itself, and
reproductive ability).
1. Red bone marrow and genital glands.
2. Thyroid gland, liver, kidneys, lungs and muscular system.
3. Skin cover and done tissue (fig. 1).

To protect population from radioactive contamination it is necessary to

protect people from general external radiation, prevent contact of radioactive
substance with skin surface, nose, ocular mucosa, penetration into organism with
air, food, water. For this purpose, radiation-proof shelters, asylums, personal
protective equipment gas mask, breathing mask, anti-powder cloth mask, as well
as gauze and cotton dressing safely protect respiratory organs from radioactive
contamination. Body surface may be protected also with ordinary clothing.
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Fig. 1. Organs where redionucleids accumulate in human organism

5. Electromagnetic impulse
At the moment of nuclear explosion numerous gamma-quanta and neutrons
spread around. The gamma-quanta and neutrons interact with environmental
atoms and create electromagnetic fields, and result in short-term, however very
strong current and voltage in air or underground communication, cable lines,
signal, electric lines, radio station antennas etc. These are called electromagnetic
impulses. Electromagnetic impulses damage radioelectronic devices, electric
devices connected to external lines. Electromagnetic impulse breaks also
semiconductor devices, gas discharge, vacuum devices, condensers. If no measures
are taken to provide safety of persons working with these devices, high electric
voltage of electromagnetic impulse may injure people. This may impact their
conduct, development and metabolism processes.

To determine the nature of destructions, amount and condition of rescue

operations, damage site is divided into four circular areas (complete, heavy,
moderate and light destruction zones).
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1. Complete destruction zone

Residential and industrial buildings with low level of protection completely
collapses. Underground community facilities collapse and get damaged. Soil and
materials burn to the ground. Unprotected people get very severe injuries (injuries
of internal organs, bone fractures, collapse, contusion, brain bleeding, severe burns
etc.).
Rescue operations possible under the situation in the zone are preparation of
passages to shelters, evacuation of people from destructed constructions and air
supply to shelters. In such conditions, work of medical aid squads becomes
extremely complicated.

2. Heavy destruction zone

Ground buildings and constructions are extremely damaged, streets of
residential areas become impassable due to ruins, underground communications
are damaged. Majority of existing buildings (more than 90%) are covered with fire.
Population in open areas suffer moderate injuries, including III-IV degree burns.
Cases of carbon monoxide poisoning may also occur in the zone.
Works to be carried out here consist of elimination of ruins, fire
extinguishing, rescue people from ruined shelters and damaged buildings. In this
zone medical aid squads face difficulties, and first aid troops do not have
conditions to work.

3. Moderate destruction zone

Partition walls, doors, windows and roofs of buildings are damaged, walls are
cracked, roof spaces and upper floors collapse.
Minor and moderate injuries, burns and carbon monoxide poisoning is
encountered among unprotected population. Majority of people with minor injuries
can leave the site by themselves (if they do not have burns). In this zone, work of
medical aid squads is limited, and first aid troops do not have conditions to work.
4. Light destruction zone
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Buildings are damaged lightly, weak partition walls, doors and windosw are
damaged partially and walls of upper floors are cracked. Basements and lower
floors remain serviceable.
People outside protective equipment may be injured by fragments of ruined
constructions (brick, concrete, roof slate, glass etc.).
Main rescue works consist of extinguishing fires and rescuing people from
partially destroyed and burned buildings. Medical aid squads and first aid troops
have satisfactory conditions of works.

Assessment of the conditions in the nuclear damage site shall consider

radiation situation which is one of the main elements of the site. Radiation
situation means radioactive substances influencing activity of rescuing agencies
and facilities, life activity of population, and scale and degree of a contaminated
area.
Assessment of radioactive situation allows to:
calculate the expected radiation dose;
determine term of operation of agencies in damage zones;
determine time of entrance of agencies into damage zones;
determine the time of escape from sites;
choose the most favorable option of operation for economic entities and
medical facilities.

Assessment of climatic and geographic conditions is extremely important for

Civil Defense Medical Service. Assessment of meteorological factors shall
consider weather conditions and temperature, precipitations, wind speed and
direction, geographic features (ground relief and nature, vegetable cover, water
resources, constructions, roads, industrial and welfare facilities, local resources),
season, day length etc. Moreover, it is necessary to find out whether there are oil
and chemical industry facilities, bases and storages of fuel, superpotent and toxic
substances. Damages to them or their demolition will even more aggravate the
existing situation. This will have negative impact on the activity of all rescue
agencies and medical service.
Issues of great practical significance (type and amount of medical aid,
demand in transportation means, medical sanitary property, medical personnel and
treatment facilities) depend greatly on the number and nature of sanitary losses.
Main elements of assessment of the medical condition mean number (amount)
and structure of sanitary losses (table 1).

Table 1. Estimated losses among unprotected population of a nuclear damage site

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Nonrecoverable
Destruction zones General losses, % Sanitary losses, %
losses, %
Complete 90 80 10
Severe 50 35 15
Moderate 40 10 30
Light 15 15

Light damages will constitute 20-40%, and severe damages 60-80% of

sanitary losses (table 2).

Table 2. Structure of estimated sanitary losses in case of application of a nuclear

weapon

Damages Amount (%) Note

Thermal burns 26.4.-25.
Mechanical injuries 26.4.-50.
Radiation damages 26.4.-15.
Including central
Combines damages 45-55 nervous system (CNS)
disorders

Sanitary losses in case of application of a nuclear weapon depend on the

nuclear ammunition, number of the population in the site, provision of the
population with individual and collective protective equipment, ground relief,
nature of constructions, design of residential areas, air, season etc.

Medical and tactical characteristics of combined damage sites

In modern times, there is a risk of simultaneous and successive application of

nuclear, chemical and bacteriological weapons. The weapons may be applied in the
following combinations:
nuclear and chemical
nuclear and bacteriological
chemical and bacteriological
nuclear and bacteriological
mass destruction weapon (MDW) and conventional weapons.

The area conditions of which require decontamination and rescue works of

ground and facilities in the result of application of two or more mass destruction
weapons or other means of attack is called a combined damage site. Situation
emerged in the site significantly differs from the situation caused by the
application of one type of MDW by its complexity and severity.
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General condition in a combined damage site differs from other sites by large
destructions, failure of communications, damage to facilities, numerous losses,
extremely severe situation, panic among the population and severity of mass
combined damages, sharp increase in the number of people in need of help.
Moreover, demand in transportation means and medical sanitary property for
evacuation of the wounded and thick will be necessary.
Combined damages in the result of impact of several weapons on human
organism:
Mass cases of:
1. mechanical injuries, burns, radiation damages;
2. mechanical injuries, intoxications, infectious diseases;
3. radiation damages, mechanical injuries, burns etc.
It is known that one damages complicate course of others. This feature of
combined damages is known as a mutual complication syndrome. E.g. radiation
disease significantly complicates course of infectious diseases. When assessing the
condition established in a combined damage site, all the mentioned factors, as well
as meteorological and geographic properties of the site, characteristics of
residential areas shall be analyzed with consequent decision-making on rational
organization of the activity of CDMS agencies and medical maintenance of
population. In such cases, medical service applies extreme postsyndrome
diagnostic tactics is applied, i.e. function of vital organs is taken to the forefront.

Unlike peace time, activity of CDMS in wartime is very complex and severe:
1. frequent changes in general conditions requiring changes in the method,
mode and place of work;
2. mass sanitary losses occurring within short period of time (among which
combined damages, multiple trauma and joint injuries will prevail);
3. increase of the risk of appearance and spread of ordinary infectious
diseases in connection with decrease in the sanitary-epidemiologic and
financial and living conditions of residential areas;
4. aggravation of the course of a number of pathologic processes
(pneumonia, gastric ulcer, pulmonary tuberculosis etc.);
5. psychological effect of modern weapons, especially, MDW, on people;
6. significant increase of rear pathologies in peace time (radiation disease,
trench foot, ttnus etc.).

Such extreme situations require deep and comprehensive analysis and

assessment of general and medical conditions by the CDMS, proper arrangement
of medical maintenance of population and prompt maneuvering.
Medical and organizational measures shall be taken in accordance with
established situation.