Communication plan needed for terrorist attack

Be prepared to ease stress levels

A terrorist attack involving a nuclear blast or dispersion of radioactive material will cause significant mental health problems in both patient and health care workers, the Centers for Disease Control and Prevention (CDC) warns.1

"There will be a significant psychological effect, particularly if it were a terrorist situation," says Fun Fong, MD, a CDC consultant and former director of radiation medicine at the medical sciences division of Oak Ridge (TN) Associated Universities. "Both victims and health care professionals will be under tremendous psychological stress. It is important to debrief people right after the event and identify those in need of counseling."

The initial reaction of many will be one of shock, immobilization, and fear, according to new CDC guidelines for hospitals. Most people will exhibit higher levels of anxiety rather than psychotic behavior, and some also will experience post-traumatic stress disorder (PTSD). Long-term psychological effects, which could arise from 48-72 hours after the incident, include anxiety disorders, PTSD, depression, traumatic neurosis, insomnia, and acute stress disorder.

Since the situation is frightening to most people, hospitals should be proactive in reassurance and communication to reduce psychological issues. Hospitals should dispense timely and accurate information, including an accurate description of the incident and its location to the public, the CDC recommends. This will allow them to take appropriate actions before they come to the hospital. Counsel patients on both acute and potential long-term physical and psychological effects. Include this information in patient discharge sheets.

Hospitals also should ensure that trained counselors are on site, and screen persons who may be at higher risk for PTSD (i.e., people who have been previously traumatized or have been in other disasters). These individuals will require follow-up.

The CDC warns that health care providers — particularly those working outside of their areas of expertise — may experience a similar array of mental health effects. Health care workers also may have concerns about long-term risk of cancer and carrying radiation home to their families. Hard decisions may have to be made about who to try to save and who not to save. "Providers are likely to have a real sense of guilt when they cannot treat everyone and are not able to do as much as possible for each patient," the CDC notes. "This concern could result in anger, feelings of helplessness, depression [potentially long term], and sleep disturbances. All of these will be aggravated by fatigue and exhaustion from response demands."

Possible physical signs that staff may be experiencing psychological effects include vomiting, diarrhea, nausea, and headaches. Unfortunately, these also are physical signs associated with acute radiation exposure.

"Psychological effects are most likely to occur among staff who have the greatest amount of contact with the deceased and/or dying and those dealing with children or pregnant women," the CDC warns. "These effects are more likely to occur with staff who are severely fatigued by being on duty for a long period of time."

The critical incident stress management strategies should include having credentialed mental health providers in place at each facility. Hospitals should have mental health providers who can dedicate time to staff support. Hospitals should screen for those who are at higher risk of psychological complications. Provider education and training are key components.

"Do not assume that practitioners know more about radiation than the general public," the CDC advises.

Staff will be concerned about their own families, so hospitals should establish a communication liaison for them. Provide for rotation of staff to reduce fatigue. Hospitals should conduct tiered levels of debriefing after a mass-casualty event to gather data and address mental health concerns. The debriefing groups should not be cross-discipline (physicians with nurses, etc.). This allows participants to express concerns more freely, the guidelines advise.


1. Smith JM, Spano MA. Interim Guidelines for Hospital Response to Mass Casualties from a Radiological Incident. Atlanta: Centers for Disease Control and Prevention; 2003. Web site: