““Basic PrinciplesBasic Principles of of Hospital PreparednessPreparedness
in Casein Case of a Terrorism CBRN Incidentof a Terrorism CBRN Incident””
ETHREAT PILOT COURSE FOR EU FRONT-LINE HEALTH PROFESSIONALS
23-25 MAY 2007
What is the aim of a terrorism act?
“Terrorism is theatre”–
like a play can be viewed as a deliberate
presentation to a large audiencein order to spotlight a message
and hold attention.But terrorism has a purpose
that goes well beyond the act itself;the goal is to generate
fear and chaos
Opposing Force: Doctrinal Framework and Strategy FM 7-100 (2003)
1 10 20 100 200
Chlorine
Cyanogen Chloride
Phosgene
Hydrogen Cyanide
Mustard
Sarin
VX
600
600x200x
13x7x
6x2x
Relative lethality in relation to chlorine (respiratory)
What agents can be used for a terrorism urban attack?
TOXIC INCAPACITATING
Choking Blood Blister Nerve
TIC/TIM
CHEMICAL AGENTSBIOLOGICAL AGENTSRADIOLOGICAL AGENTS
“To produce about the same number of deaths within a square mile,it would take:
32.000.000 grams of fragmentation cluster bomb material;3.200.000 grams of mustard gas;
800.000 grams of nerve gas;5.000 grams of material in a crude nuclear fission weapon;
80 grams of botulinum toxin type A;or
only 8 grams of anthrax spores”
Louis GuiffridaFormer FEMA directorAnn International Journal (1987)
What are the targets for a CBRN terrorism attack?
Mass gathering places
Shopping mallsBig buildings (e.g. ministries)Health facilities (e.g. hospitals)Athletic installationsAirports, train stations, portsEntertainment installations (e.g. theaters)
Industrial infrastructures in urban areas
Pharmaceutical industriesPesticide plantsWater/Sewage treatment plantsChemical storage facilitiesPetroleum refineriesPower generation plantsLandfills
What are the ideal conditions for a terrorism CBRN urban attack?
Winds
Temperature(high = low persistency)(low = high persistency)
Rain(hydrolysis of agents = reduces effectiveness)
Atmospheric stability(inversion/lapse)
Epidemiological clues of a CBRN terrorism attack
CHEMICAL/RADIOLOGICAL BIOLOGICAL
Rapid onset of similar symptoms amongvictimsVictims originate from same areaAbrupt onset of symptoms in a closedor semi-closed industrial areaExplosion, fire, spill or release of vapor under pressure or from open containersUnprotected rescuers becoming victims themselves
Rapidly increasing flow of patients in EMSAtypical epidemiological curveUnusual increase of patients with fever, respiratory or gastrointestinal symptomsPandemic out of seasonMost patients were out of buildingsVictims originate from same areaPatients die in short courseSimultaneous symptoms in humans and livestock
Possible scenarios of CBR attacksUse of weaponized CBRN substance or attack on a weapons
stockpile
Aerosol spraying (handled devices, crop dusters)
Attack on industrial/commercial chemical sites
Intentional hazardous materials transportation mishap (truck, rail car or
tanker with chemicals)
Immediate identification of specific chemicals is usually not possible
CWAs
Hospital preparedness
Percentage of hospitals that trained their staff in emergencyresponse, by selected subject areas
Percentage of hospitals that trained their staff in terrorism response, byprofessional category
Percentage of hospital that trained their staff in bioterrorism response, by biological agent
Hospital preparedness
15 States: Highest preparedness level to provideemergency vaccines, antidotes, and medicalsupplies from the Strategic National Stockpile
25 States: Would run out of hospital bedswithin two weeks of a moderate pandemic fluoutbreak
40 States: Face shortage of nurses
Rates for vaccinating seniors for the seasonal fludecreased in 13 States
11 States and D.C.: Lack sufficient capabilitiesto test for biological threats
4 States: Do not test year-round for the flu,which is necessary to monitor for a pandemic
6 States: Cut their public health budgets fromfiscal year (FY) 2005 to 2006; the median ratefor state public health spending is $31 per person/year
531 European Front Line Health Professionals from 22 countries50.6% reported a National CBRN Plan67.1% were aware of a POC in case of deliberate incident68% had last CBRN training >24mo or never28.5% had high confidence in their PPE35.9% had access to PPE in workplace
Discriminate natural vs. man-made incidents:31.6% (chemical)30.3% (biological)27.3% (radiological)
Prepared for:Chemical – 37.2%Biological – 46.8%Radiological – 28.6%
Level of knowledge regarding:Anthrax – 64%VHF – 57.6%Nerve agents – 42.9%Mustard gas – 34.7%
93 CBRN Experts
from 16 countrieson FLHP preparedness (>50%):
Chemical – 19%Biological – 20.7%Radiological – 8%
On-siteVictims(remain)
Dead orSeverely injured/affected
~20%
What is the “real” picture at the incident site?
On-siteVictims
(escape)
Less/Not affectedwill run to the
incident’s perimeterhospitals~80%
Whelm ALLhealth care facilities
“Worried-well”1:5
Peoplefrom
the “outside”
Will go insidein order to assist casualties
(=more victims)
Possible health threats for the on-site very first responders
RULE ofRULE of1 1 –– 2 2 –– 3 3
1 DOWNCould be medical
2 DOWNCould be medical but be cautious:it might be something else
3 (or >3) DOWNStay awayPut escape hood on (if available)Secure perimeterAsk for back-up/instructions
What is the usual response of first responders?Rush in trying to help wounded or affected contaminated
State response following terrorism CBRN incident
Should be fast: “time is life”
Should be multilevel / parallel
Should be tested through constant exercising
Should be constantly evaluated / revised
Should be highly motivated
“Rule of 16”
First aids on site
EMS personnel in PPE
Control hemorrhageSupport breathingProvide antidotes
Apply triageS.T.A.R.TJumpSTART (children)
Scenario 1 – The Israeli model
Incident site Hospital
Decontamination “en-route”
Scenario 2 – Known target
HospitalIncident site
Scenario 3 – Random single/multiple target(s)
Incidents’ site Hospital
Victims
Evacuationof casualties
Hospital defense following a terrorism CR incident
Distancefrom hospital
Far away from hospital
Close to hospital
Within hospital premises
Adequate Reaction Time
Limited Reaction Time
No Reaction Time
Availabilityof fence
Fence: Available
Fence: Not AvailableCrowd control possible
Crowd control impossible
Availabilityof Security Forces
Populationidiosyncrasy
SF: Available
SF: Not AvailableGate control possible
Gate control impossible
PreparednessLevel of knowledgeObey instructions
Motivation for assistance
Decontamination of casualties
ON-SITE
AMBULATORY
WEATHER
DECONSITE
AT HOSPITAL
TYPE OFCASUALTIES
NONAMBULATORY
SPECIALCONSIDERATIONS
GUNS,GLASSES,
DISABLED etc
Psychological toxicity (PT)* –
the perfect weapon!
A form of venom that poisons a person, community or society. Its net effect is to destroy healthy substrates creating dysfunction,impairment and perhaps even death
13 putative mechanisms of PT:
A stealth, unpredictable pattern of attackAbility to affect large numbers of victimsIntent to harm noncombatantsEase of weapon deliveryDelay & difficulty in assessing exposureLong incubation periodPotential of contagionPotential to scar and disable rather than killAbility to overwhelm public healthAlteration of the accepted & preferential way of lifeMotivation that is immune to rational, measured deterrenceUse of self-destruction as a weaponAll-or-nothing strategic thinking (*) Everly GS Jr (2003) – International Journal of Emergency Mental Health, (4:245-52)
“Worried well”
Contaminated 1Worried-well 5
Psychosocial triage
Rapid oustingPharmaceutical calm-down Provide written instructionsStress desensitization
Hospital CBRN Equipment
Decontamination equipmentIndoorsOutdoors
PPE forSecurity forcesDecontaminationPhysicians/nurses
Post-decon clothing for victims
Medical equipmentSingle-use for first aidsStretchersSpecial equipment for chemical
environment
Defense equipment (e.g. pepper sprays)
Communication equipment
Hospital CBRN Response Personnel
EMS Personnel
Triage by most experienced (fit)general surgeon
Front line specialists
OphthalmologistsChest physiciansDermatologistsBurn unitICUPsychiatrists – psychologists
Security personnel
In a real CBRN terrorismincident ALL personnel are
becoming EXPERTS
Training Hospital CBRN Personnel
Motivation
Selection of personnelTraining in all levels of PPERegular medical check-upsContinuous acclimatization in PPE
Hospital table-top exercisesHospital field exercisesNational medical CBRN exercisesNational multi-agency CBRN exercises
Continuous revision of strategiesCME
Disaster don’t happen to placesDisaster happen to peopleDisaster can happen to us!
Disaster don’t happen to placesDisaster happen to peopleDisaster can happen to us!
Hospital stockpile
PharmaceuticalAntibiotics & antidotesFluids, bandages, IV suppliesSupportive care medsVaccine & antitoxin
Critical equipmentVentilators
Ethical dilemmasWhen to stop/remove ventilators
Agent Treatment
Nerve Agents 2-PAM, Atropine, Diazepam
Vesicants Supportive care(BAL for Lewisite)
Industrial Chemicals Supportive care(CyanoKit™)
Riot Agents Supportive care
Green = Chemical Red = Explosion/Burns
Atropine + 2-PAM / diazepamHospitals 15% auto-injectorsEMS 85% auto-injectors1000 victims 30-40-30%
CHEMPACK
Corps’ Management
Mortuary
Restoration of hospital
Decontamination of outdoors area (e.g. parking lot)
Decontamination of EMS facilities
Decontamination of decontamination facilities
Decontamination of decontamination equipment
Decontamination of ambulances
Contaminated equipment management
Contaminated waste management
Verification/certification of decontamination
X
X
X
XX
X
HOSPITAL
SUPPORTHOSPITALS
DECONSTATION
HZWZ
DISPERSION OF CHEMICAL CLOUDDEPENDING ON WIND DIRECTION
X
XX
X
X
DECONSTATIONHZ WZ
DISPERSION OF CHEMICAL CLOUDDEPENDING ON WIND DIRECTION
HOSPITAL
HOSPITAL
HOSPITAL
X X
X
XX
DECONSTATION
WΖ
HΖ
DISPERSION OF CHEMICAL CLOUDDEPENDING ON WIND DIRECTION
HOSPITAL
SUPPORTHOSPITALS
X
X
X
XX
X
DECONSTATION
HΖ
WΖ
DISPERSION OF CHEMICAL CLOUDDEPENDING ON WIND DIRECTION
HOSPITAL
SUPPORTHOSPITALS
Victims
Physicians
Nurses
Medics
Security
EMS
DetectionStationTriage
Station
First AidStation
Non AmbulatoryVictimsDecon Station
Mass DeconStation
Mass DeconStation
VerificationStation
+-
1st RespondersDeconStation
T
HOTZONE
COLDZONE OUT
DeconSolution
WorriedWell
Corridor in/out
SupportStation
Stretcher Parking
Conclusion
