 If and when the war of guided missiles erupts from the sky, these awesome weapons will carry nuclear warheads. This is one of a series of films demonstrating the current doctrine and operational principles for the medical management of mass casualties incurred in a nuclear weapon attack. Following such an attack, a great disparity will exist between the medical requirements and the medical resources. The purpose of this film is to demonstrate the accepted principles in the management of psychological casualties. Within the area of the actual blast, there will be great destruction, death and injuries in large numbers. However, even beyond the periphery of such a blast area, many injuries will result from flying debris and secondary fires. In addition, although they may escape injury, many will show varying degrees of non-effectiveness. This will be due to the emotional impact of being exposed to massive physical destruction and great personal danger. Mass panic in disaster conditions will be rare. Sudden flight may be common, but such behavior is not panic if it is self-controlled or successfully directed by others. In fact, instantaneous flight or rapid taking of cover may be the best possible way to survive under such threatening circumstances. As long as flight is not blocked and escape routes are open, mass panic is unlikely to occur and is therefore preventable. In from 15 to 20 percent of the survivors, actual danger will produce alertness and increased efficiency. Prior training or experience will increase the likelihood of this favorable reaction. However, the majority of individuals will be unable to cope with such a catastrophic experience immediately, particularly if it is unexpected or prolonged. The sudden obliteration of their surroundings, the sound and fury of the blast, will make it difficult to respond or react promptly and effectively. Great fear will interfere with the ability of many to understand what has happened or to decide what they must do. After seconds or minutes, however, most of them should recoil and develop sufficient awareness to take steps for personal survival. During this recoil period and for a time thereafter, such survivors may be influenced by the commands and activities of leaders or other survivors. Perhaps five to 20 percent will not rebound immediately. They will continue to be non-effective for hours, but rarely for days. Some may continue to be stunned or dazed. It is to this group alone that the designation psychological casualty may be properly applied, or to use the terminology of World War II, the form of combat fatigue. Most of the survivors of a nuclear attack will react in ways which must be regarded as normal responses to stress of such severity. These reactions are not necessarily disabling and may render individuals only temporarily non-effective. These people will experience sensations and will behave in ways commonly encountered among disaster victims. Some may have tension headaches, a momentary freezing of muscular activity, temporary difficulty with speech, trembling or occasional gross shaking. Others may suffer from nausea and vomiting, overactivity of the sympathetic nervous system, sweating of hands and feet, rapid heartbeat, giddiness or breathlessness. Still others may exhibit such psychological manifestations as a passing apathy, helplessness, docility, sadness, resentment, pain, some overexcitability with laughter or tearfulness and restlessness. All these symptoms are normal disaster reactions. Individuals suffering them will be unhappy, uncomfortable and distressed, but they will be non-effective for only a very short time and should not require specialized medical treatment or management. If their difficulties are not to be prolonged, it is important that the nature and significance of their reactions are understood by their leaders and by those about them. Such persons who are immediately available must provide them with direction, firmly encourage their prompt return to effective function. The reassurance and support of nearby and familiar medical personnel may help in this brief but highly effective type of psychological first aid. Only when despite such efforts, the abnormal behavior persists. Should psychological casualties be considered psychiatric problems, requiring specific medical treatment for their combat fatigue. About 50 to 70% of those whose symptoms persist will be suffering from a mild incapacity. Some of these may connect their fears and anxieties with strong beliefs that they are suffering from heart disease, irradiation sickness, concussion, stomach trouble and the like. Symptoms ordinarily associated with internal injuries or disorders, burns or other minor injuries may serve as a focus for undue bodily concern. Such patients may demand aid with excessive tearfulness or anger. They may wander about aimlessly, doing meaningless things. Others of this mild type may exhibit restlessness and become overtalkative. Because they cannot concentrate on or complete a single task, they will be almost unable to function with others. Approximately 30 to 40% of the psychological casualties will be of a moderate type. They will look sick and disabled. They may have difficulty talking. Others may be agitated with marked anxiety and tension. Some in this moderate group may suffer from a reactive depression. They may have lost a buddy in the attack and may display obvious grief. They will exhibit actual tears only occasionally. Still others may suffer from hysterical blindness, deafness, loss of memory or voice. Some may have a paralysis of one or more extremities, brought on perhaps by a minor injury or by the blast wave. They will characteristically present a bland indifference until efforts are made to remove the symptom. Then tension mixed with anger may appear. Finally, in this moderate group, there may be those who continue to be stunned and distaste by their experience. They may exhibit severe apathy. Questions will be answered only in monosyllables. There will be no evidence of tears, depression or anxiety. Because they seem absorbed in themselves or puzzled by their experiences, they will exert little effort to do or to say anything. They will seem unable to understand what has happened to them. Approximately 1 to 3% of the psychological casualties will be in the severe group, clearly out of contact with reality, exhibiting uncontrolled actions which are purposeless and undirected. Because they respond without discrimination, self-injury may result. It will be impossible to reason with them and incoherent shouting will sometimes occur. Also in this severe group, will be some who exhibit a complete withdrawal from their environment to a helpless infantile state. They will be muped, motionless, with little reaction to stimulation. At times they can be led, much like a small child. But such manifestations may change in a matter of minutes, rather than hours or days. Usually the change will be in the direction of improvement with increased self-control and more effective behavior. Even the severe psychological casualty can be expected to improve within hours, within days at most, depending upon the kind of treatment he receives. There are certain basic principles to be followed in the treatment and management of mass psychological casualties. This must be remembered. Most of these casualties will be suffering only temporary emotional disturbances. They can be expected to improve as the danger lessens. Therefore treatment must be made available as soon as possible and as near as is practical to the scene of the nuclear disaster. Most of the mild cases of freezing, indecision, and helplessness can be handled best by their buddies, by their commissioned or non-commissioned officers, or by medical corpsmen. Many of the casualties will be readily influenced by suggestion and other simple measures to recover self-control. For this reason, early treatment can produce an improvement before time and continued helplessness have fixed a temporary condition into a chronic disorder. This will prevent psychological casualties from overloading evacuation channels and medical facilities unnecessarily. Immediately after the blast, these facilities must be reserved for the treatment of casualties with physical injuries. However, individuals who do not recover their effectiveness as a result of reassurance, leadership, and direction should be evacuated to the nearest aid station or medical sorting team. They should be evacuated as walking wounded if possible, by litter only if absolutely necessary. In nuclear warfare, the battle group surgeon will normally assume the role of a frontline psychiatrist. He will thus conserve the fighting strength of his unit at a time when every man will be vitally needed. Mild cases, if they reach medical sorting teams or aid stations, will be placed in a holding category. There they will be allowed to rest, talk to others, and regain self-control. Careful sorting and early corrective treatment at the aid station level can promptly restore vitally needed trained manpower urgently required for defensive and rescue tasks. Psychological casualties should be encouraged by reassurance of recovery to aid them in accepting their condition as being only temporary. Encouragement by the treatment personnel can help provided it is stated with conviction. Their calm acceptance of the casualty and their attitude that the symptoms are only temporary can produce the desired improvement within a matter of hours, especially after certain treatment procedures have been followed. These procedures should be simple and brief, not only because of the lack of personnel and time, but because straightforward simplicity avoids the suggestion of serious illness. Early measures to relieve thirst, pain, and minor injuries can provide the most favorable conditions for return to duty. If available, small doses of a sedative with warm milk, soup, or cocoa can promote relaxation, although the warm drink alone can often serve the purpose adequately. A rest period of several hours is also indicated. Later, if time permits, the psychological casualties should be interviewed briefly and should be encouraged to relate his experiences in the disaster. This will give the casualty an opportunity to talk about himself and express some of the feelings and attitudes that may be responsible for his symptoms. It will also encourage him to respond to others so that he can be motivated to return to duty. The final stage in this brief and simple treatment consists of giving the casualty directed and supervised duty assignments. Preparatory to their return to duty, improved cases, can be readily put to work at some part of the salvage, rescue, or medical mission. With this return to activity, their ability to work with others will improve, and they will be led further toward resuming their normal activities. Immediately after a nuclear attack, transport for medical evacuation will be reserved primarily for the physically injured. However, when these facilities become available, the severe persistent psychiatric cases should be evacuated. This will normally be to the Division Psychiatric Treatment Center. The division psychiatrist and his staff will usually be found at the clearing station. During the initial phase, the division psychiatrist may be largely occupied with assisting in the sorting and treatment of the physically injured. In this period, the psychiatrist may restrict his specialized activities to the supervision and direction of the division social worker. The social worker will provide the immediate treatment and supervision of the patients. After the emergency has passed and the situation has stabilized, the psychiatrist will resume his active specialized medical function. In summary, all military personnel must be prepared to treat the psychological casualties which can be expected in nuclear warfare. They must realize that the common psychological reactions to be expected after a nuclear attack will be states of temporary disturbance. These can be expected to improve rapidly as the danger lessens and without specific medical treatment. Most of these individuals can be aided by those about them. The treatment of psychological casualties should be based upon principles that include treatment as soon as is practical and as near as possible to the disaster area, assurance of recovery and brief simple procedures to include feeding, rest and interview. Remember, treatment should be started in the field. Sorting and if at all possible, active treatment should be provided by any medical facility receiving psychological casualties. Proper sorting and management can be highly effective in preserving manpower. Most important, in the early phases of a nuclear attack, directed work and other steps to improve effectiveness will not only shorten the period of abnormal behavior, but will save lives, reduce disability and in general, lessen the inevitable confusion and chaos resulting from a nuclear attack.