• William W. Forgey, MD


Excerpt from The Prepper's Medical Handbook. Page reference numbers point to more in-depth treatment and self-reliant care available within the book.

Four possible events can trigger significant radiation exposure (beside natural background and medical testing):

  1. Nuclear bomb

  2. Nuclear power plant disaster

  3. Terrorist dirty bomb

  4. Accident in transport or storage of nuclear material

When selecting a possible survival retreat, it should be possible to avoid being at a ground-zero location for any of the above. The issue then becomes how to minimize the effects of radiation spreading from one of those locations. It is obvious that many metropolitan areas could be targets for intercontinental ballistic missile attack, and if they are, they would probably receive multiple hits due to redundant targeting. The locations of nuclear power plants are well-known, and the greatest danger from them is a natural disaster that causes a plant malfunction, or terrorist destruction of an individual plant or mass attack via hacking controls. We need to evaluate the extent of the plume danger, including its potential distance and contents, and develop strategies to counter this danger. Bomb plumes are one thing; continuing plumes from a malfunctioning nuclear plant are another. A dirty bomb, consisting probably of an enriched nuclear material detonated by a conventional explosion, will have a different isotope danger, with intense local long-lasting radiation, but a minimal distance to its plume. Transport accidents will be localized along a rail or road corridor, will have a specific isotope release, and will probably be an isolated incident that will bring the grid authorities scrambling to clean up and cordon off the area, with localized plume and runoff contamination from surface water.

The isotope release and plume from nuclear bombs has been extensively studied with regard to bomb construction, yield, and burst height, including subsurface, ground, and water detonations. The lethality and injury estimates have also been extensively predicted for various distances from ground zero for ground and air blasts of various yields from nuclear detonations.

A nuclear device detonation releases 40 to 50% of its total energy as blast overpressure, 30 to 40% as thermal heat radiation, 5% as ionizing radiation (more in a neutron bomb, which has much less blast energy), and 5 to 10% remains as residual radiation.

For those victims too close to ground zero, the rates of death and survivable injuries will be related to blast and heat injury, but if we have chosen our retreat location well, we will have avoided those immediate injuries, and the concern for most preppers will be the immediate fallout radiation from the plume and then managing longterm residual contamination. But if you are caught near a detonation location, the chance for survival increases dramatically by using the 1950s technique of “duck and cover” immediately upon the bright light flash, by not looking in the direction of the blast, and by sheltering. The shock wave will cause immense physical damage directly and from flying debris.To survive and minimize the blast energy and the thermal heat and to minimize the ionizing radiation, stay put in the nearest building for 2 to 24 hours. The length of time to safely leave and evacuate depends upon the ionizing radiation release and the protective value of the shelter. During the height of the cold war, buildings were graded by a protective factor up to R20, the ideal protective covering for the ionizing radiation phase of the blast, but most buildings provide at least some protection, and one should evacuate to a more obviously protective shelter only when the withering initial ionizing irradiation period has passed or decreased so that increasing one’s outside exposure briefly to move to an R20 level building is worth it.

There are different antidotes for the various isotopes, and length of administration depends upon exposure characteristics. We will focus on minimizing these dangers and radiation illness in this chapter.

The topics we need to study therefore include the following:

  1. Units of radiation measurement

  2. Measuring and estimating safe exposure limits

  3. Neutralizing immediate fallout and decontamination of residual contamination

  4. Managing long-term radiation exposure

  5. Treating radiation sickness

If someone is caught near a blast location, minimizing damage from overpressure trauma, flying debris, direct radiation, and thermal burn must be done by finding immediate physical barrier protection and, if wounded, treating burns (page 139), orthopedic injuries (page 154), lacerations (page 116), injury from foreign bodies (page 38), and eye injuries (page 36). Radiation sickness prevention and treatment follows.


Roentgen is the unit of actual exposure, defined as ionizations per unit volume of air (measured by Geiger counters and ionization chambers). The rad is the amount of radiation energy absorbed per unit of mass. Neutron radiation causes more damage than gamma or X-ray radiation. A conversion is made by this degree of damage to form a unit called the rem, or roentgen equivalent in humans. The international system outside of the United States makes the following substitution: Rad is replaced by the gray (Gy), and rem is replaced by the sievert (Sv).

1 Gy = 100 rad

1 Sv = 100 rem

The quantity of radioactivity is expressed as the number of nuclear

disintegrations per second. One disintegration per second is called 1 becquerel (Bq) in the international system. In the United States one curie is 37 billion Bq.

When describing X-ray, beta, or gamma radiation, the rad and rem (and Gy and Sv) are essentially the same.

Ionizing radiation damage (the rem or Sv) is accumulative. When worn continuously, dosimeters can provide insight into this accumulative dose or, with modern electronic systems, can indicate dose accumulations by various time frames so that workers in radiationexposed occupations can be kept below an acceptable accumulative risk (see figure 4-1). A Geiger counter measures radioactive emissions, mostly beta and gamma rays, in becquerels, and can be used to identify points of contamination.

Figure 4-1.

Graphical Comparison of Electronic Personal Dosimeters

Rate range (minimum and maximum): The range of exposure rate that the product can measure within an accuracy of ±30%. All quantities in this table are expressed in units of Roentgen (i.e., of Milliroentgens per hour and Roentgens per hour) to simplify product comparisons. Quantities have been converted by using the approximation 1 R ≈ 1 rem ≈ 1 rad. Specifications in Sv were first multiplied by 100 to convert Sv to rem. Note: 1,000 mR/h = 1 R/h

Source: Radiation for Response and Recovery Market Survey Report. US Department of Homeland Security, June 2016. Radiation-Dosimeters-Response-Recovery-MSR_0616-508_0.pdf.

Other devices can measure accumulated or current dose, and identify the isotope source and type of radiation. The effect of radiation on people depends upon the intensity of the dose, how focused it is, and the duration of exposure. A whole-body dose of 4.5 Gy (450 rad) delivered in minutes to hours will cause significant illness and possible death, while 10 Gy (1,000 rad) delivered to a focused area over a long period of time (such as in radiation therapy) might be well tolerated. Thus, while we tolerate easily a normal daily exposure of 0.6 rads, mild symptoms will occur at a sudden exposure to about 30 rads; between 30 and 200 rads, the person may become ill; from 200 to 1,000 rads the person will become seriously ill; and above 1,000 rads the dose will be fatal.

If people can protect themselves from the immediate irradiation from the detonation, they next must deal with fallout and radiation from contamination, which may be external or internal.

Severe local fallout, extending way beyond the blast and thermal effects, is increased by larger yield and a near surface burst that will suck up vast amounts of particulate matter. This irradiated material starts to fall in a downdraft even as the cloud rises, but the obvious smaller particles form the classic oval fallout pattern, mostly downwind from the blast center.

The low yield atomic (fission) bombs used in the Trinity (19 kt), Hiroshima (12.5 kt), and Nagasaki (2 kt) blasts did not produce sizable fallout. The damage was all due to blast and immediate radiation effects. Larger tests such as those at the Bikini Atoll and virtually all of the Chinese above-ground tests have produced sizable fallout.

The explosive energy of any fission bomb is about 90% of the actual total yield, leaving 10% as residual radiation composed mostly of fission products. A fusion (hydrogen) bomb will release 95% of its explosive energy.There are no known biological effects of the electromagnetic pulse generated by the bomb, but this can induce long cables to generate high voltages, destroy unshielded electronic devices, and cause a short period of radio and radar blackout. Electronics can be shielded by wrapping them completely in conductive materials such as aluminum foil.

With surface or near-surface bursts, the fission products of the bomb are incorporated into materials scoured from the earth. About 200 different radioactive substances are formed by fission, with additional ones created by neutron irradiation of weapon parts, soil, and other material drafted into the explosion. These materials will emit beta and gamma radiation with various half-lives, meaning the length of radioactive decay and danger will differ. Much of this is carried high into the atmosphere by large fireballs, with the fallout spreading in a downwind oval pattern. Leftover fissionable material from the bomb will be negligible and found only in the immediate vicinity of the blast downdraft where harm from the heat and previous blast effect will be of much greater concern. A homemade dirty bomb, simply a conventional explosion of radioactive material, will have a very dirty immediate-vicinity effect but a minimal plume. In a large, properly detonated nuclear bomb, there is no immediate vicinity left.

Even hundreds of bombs going off in Europe, Asia, and North America will not be the end of the world. A 5-megaton bomb surface burst would carry aloft about 2 million tons of other materials in the stem and mushroom cloud.The material that returns to earth over the next ten years is almost entirely soil with a concentration of radioactive material of less than one-tenth part per million. Surviving the blast, our job as survivalists is to make sure we increase our chances of dealing with fallout, and here is how we will do it.

An accurate estimator of radioactive decay of mixed fission products is the “7-10 rule.” Radiation intensity will decrease tenfold for each sevenfold passage of time. In other words, fallout radiation measured 4 hours after the blast will be one-tenth that reading at 28 hours after the blast. The fission radiation is a component of initial radiation during the first minute. At one hour after the blast, the radioactivity of the fission-product mixture is about 125 times less than it was at one minute.

The heavier particles that fall to the earth in a manner of hours contain most of the radioactivity produced by the explosion, but luckily much of this is locked within glassy particles, shielding or containerizing some of the radiation.

A peak dose of 0.5 R/hr, the accepted level above which a fallout threat is recognized, extends from a distance of 210 to 310 miles downwind from this 5-megaton bomb surface burst (a very dirty explosion with the most immediately dangerous fallout) with a 15 mph wind (figure 4-2).

The protection factor is the degree of decreasing radiation exposure offered by various substances and buildings. Figure 4-3 illustrates the various levels of protection within a metropolitan building.

And why is this important?

Figure 4-3.

Levels of Protection

Note: Areas near windows and at street level have less protection than inner areas; even basements of frame houses provide between 10 and 20 protection factor (PF). This means that a twentyfold decrease in radiation from outside exposure would be encountered in that position. It is not hard to develop a simple construction that can increase the PF to 100, even higher (see chapter 6, DCPA Attack Environmental Manual, Defense Civil Preparedness Agency, US Dept. of Defense, June 1973). Single-story homes with average basement wall exposure aboveground of less than 2 feet will provide PF 20 throughout the basement. Homes with two or more stories and a basement with no more than 2 feet exposure will provide at least PF 40 throughout the basement.

Source: DCPA Attack Environmental Manual, chap. 6, panel 18. Defense Civil Preparedness Agency, US Department of Defense, June 1973.

The accumulative doses of radiation indicated in table 4-1 are a guide to how much danger the exposed patient will experience. As can be seen, the damage from radiation is sustained by both the rate at which exposure occurs and the total accumulative dose.

The shelter with a 46 protective factor shows the one-week calculated dose to be 248 R, just short of the 250 R shown in the dose-penalty table, so few if any deaths would be expected. At one month the dose would be 294 R and that person would have 56 R “to spare.” Since the dose outside would be nearly 2 R/hour at one month, not much time could be spent outside without exceeding the body’s repair capability (see table 4-2). In certain circumstances, it might be wiser to use the “spare” dose during the second week to move out of the heavy fallout area. If equipped with measuring equipment one could calculate the real exposure risks allowing for safer evacuation timing. Improve the protective factor of the location by preventing dust from settling inside or rinsing it away. Removing dust-covered clothing and footwear and rinsing dust from the skin and hair will reduce this radiation by 90%. Dust will accumulate beneath belts and waistbands, neck and shirt openings, and on footwear and exposed skin anywhere. Removing this dust reduces the radiation by another 5%.

Beta burns occur only if fallout is deposited on skin during the first day or two following detonation; otherwise the decay of this form of radiation is so rapid as not to cause issues. These beta burns would appear about 2 weeks after the exposure and will generally heal well when treated as described on page 139 (burn care).

Of the many residual radioactive components of fallout from a nuclear blast, the most serious are radioactive iodine (131I), strontium (89Sr, 90Sr), and cesium (137Cs). Due to its short half-life, radioactive iodine could exist as a hazard for at most a month. It is particularly hazardous to children whose thyroid is much more vulnerable to this exposure than in adults. Radioactive iodine is a major concern of nuclear power plant meltdowns due to the ease by which iodine vaporizes and can escape the reactor and auxiliary buildings, unlike the majority of the other heavier isotopes that remained primarily contained, unlike with a bomb. (See, especially Appendix B for a full isotope hazard list).


Clearance of iodine is age dependent and proceeds based upon two biological half-lives: one of 6 hours (elimination of the whole body fraction, about 70%) and one of 100 days (elimination of the thyroid fraction, about 30%); 80% of this excretion is via urine. As of 2018, the World Health Organization (WHO) states that risk over 1 cGy (1 rad) is appropriate to initiate iodine blocking treatment, while the FDA feels it should be 5 cGy (5 rad) from their evaluation of the Chernobyl data. Treatment of radioactive iodine exposure consists of loading the thyroid with stable iodine as quickly as possible

WHO’s recommended dose is 130 mg of potassium iodide, 65 mg for children ages 3 to 12 years (FDA states 65 mg for all school-age children), 25 mg for infants and children ages 1 month to 3 years, and 12.5 mg for neonates from birth to 1 month. If using iodine-potassium iodide solution (Lugol’s solution) 1%, adults need 80 drops, children 3 to 12 require 40 drops, children less than 3 years old use 20 drops. The highest priorities for treating are newborn babies, breastfeeding mothers, and children. Dosing before the exposure (immediately after the incident and prior to the arrival of the radioactive contamination) does the most good. A single administration of stable iodine is usually sufficient.

Treatment more than 24 hours after exposure may do more harm than good by prolonging the excretion of the radioactive iodine already absorbed by the thyroid. Similarly, continued dosing does less good than an adequate dose pre-exposure (before the plume hits), as a fully saturated thyroid will not absorb much additional iodine unless a very large additional supply is offered to it. And even that additional supply of protective iodine will dislodge what is already there and sweep some of the radioactive material in with it. Iodine transfer into the thyroid takes place via complex sodium/iodine symporters, or transmembrane glycoproteins that act as a carrier, transporting the iodine across the basolateral membrane of the thyroid. The rare exception to requiring additional iodine would be in the case of continuous high-iodine plume exposure from a melting reactor (not bombs during the first few days of attack)—an unlikely scenario that would have to find you just sitting there, not evacuating, and one causing much more difficulty than radioactive iodine isotopes, requiring emergency evacuation regardless. You do not need a prescription to obtain potassium iodide pills (sold under brands names such Iostat, ThyroSafe, ThyroShield), but please note the dosing I discussed as opposed to what you read in much of the prepper literature. Also, the storage life is virtually unlimited, not 5 to 7 years.

Ingestion or inhalation of particulate fallout material is particularly difficult to treat, so masks sufficient to filter out fine dust during the fallout plume phase are essential, even wads of cloth wrapped around the face as necessary.

Insoluble Prussian blue is a compound that can remove radioactive cesium and thallium from the body, effectively reducing the biological half-life by binding to these compounds and allowing them to be defecated. Take 3 grams by mouth 3 times a day for 30 days (minimal dose). The total duration of therapy would ideally depend upon measuring residual radiation. It is important to be on a high-fiber diet to prevent constipation while on this product, and the tablets can be taken with food. It can also lead to low potassium levels.

Tritium (radioactive hydrogen) is removed internally by increasing the intake of water, 3 to 4 liters per day. This can reduce the effective half-life from 10 days to 2.4 days, and the increased water intake does not need to extend beyond a week. See page 258 about the issue regarding overhydration and hyponatremia.

Uranium is chemically toxic to the kidney by itself, but when irradiated, the radiation risk prevails. Uranium speeds through the body fairly quickly, and this can be increased by the use of sodium bicarbonate, 2 tablets every 4 hours until the urine reaches a pH between 8 and 9, or one acetazolamide 250 mg tablet. Urine pH can be evaluated by common urine test strips, or simply give these tablets every 4 hours for 2 days.

GI tract contamination for americium (241Am), cobalt (57,59,60Co), plutonium (238,239,249Pu), and polonium (210Po) is complementarily treated with aluminum hydroxide 10 mL with 1.2 g, 60 to 100 mL orally or barium sulphate 100 to 300 g in a single oral dose in 250 mL of water.

Strontium (85,89,90Sr) requires very rapid early treatment with ammonium chloride 0.5 g, 4 tablets every 8 hours. Ten grams of magnesium sulfate speeds up digestive tract transit and reduces absorption. Radioactive barium and calcium are striated similarly, with immediate blockage of absorption and inducing diarrhea to prevent absorption of ingested particles.

The above are adjunctive treatments for decontamination, but additional intravenous medications would normally be given also, such as trisodium calcium diethylenetriamine-pentaacetate (CaDTPA) in advanced treatment centers. Obviously, anyone with access to professional help during a nuclear emergency would seek it, but the above synopsis of decontamination techniques—of which the most important is the replacement of clothing, the washing of hair and exposed skin and to take actions to prevent inhalation and ingestion of radioactive particles and gas—may be all that a prepper has available.

When suspecting contamination, the entire body should be surveyed using a thin window Gieger-Müller probe attached to a survey meter. Lacking any of the appropriate equipment, the prepper may have to evaluate the amount of illness by patient symptoms.

There are several symptom phases possible. An exposure range of 1 to 2 Gy (100 to 200 rad) may have nausea and vomiting onset within 2 to 6 hours, which lasts less than 1 day, no diarrhea, slight headache, no fever, maybe some fatigue and weakness. An onset to vomiting of 1 to 2 hours will occur in 50 to 100% of people exposed to 2 to 6 Gy, and it will last 24 to 48 hours; they may develop bruises and hemorrhage and infection about 3 weeks after exposure. Exposure to 3 Gy will result in hair loss in about 3 weeks. While death may occur in 5 to 50% of these people within 4 to 6 weeks, this means that most in this exposure range will survive. Above 5 Gy (500 rad) of sudden exposure, survival without advanced care to provide white cell stimulation medications and appropriate IV fluids is unlikely.

Then what do you do? You return to the basics of what we always do in a remote area, practicing medicine in an austere environment. It’s basically down to supportive care.

Nausea/vomiting/gastritis treatment as per protocols, see page 70. Diarrhea as per protocols, see page 72.

Fever as per protocols, see page 29.

Even when developing these symptoms, including infections from temporary suppression of the white blood cell counts, these people may survive for many years in good health once through this rough beginning. Receiving advanced medical care, including injections of medications that stimulate blood formation, would, of course, be performed in advanced treatment centers. As with any terrible tragedy, the focus is on supportive care, not making things worse, and not giving up.

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