Maximum casualties Preparing your office for an infectious ......Survival Skillsis the bible on...

PLUS...Take a seat at the table or find yourself on the menu

It ain’t brain surgery

I have three tails or how one visit can wreck a career

Volume 17, Number 1

Spring 2006

Maximum casualties

Preparing your office for an infectious disease emergency

The role of amateur radio in disasters

Maximum casualties



AzMedicine Spring 20062

Spring 2006 AzMedicine 3

From Our PresidentWe were ready, but were we needed? . . . . . . . . . . . . . . . . . 4

PerspectiveI have three tails or how one visit can wreck a career . . . 24

Medical Liability UpdateDisaster preparedness in the physician’s office . . . . . . . . . 26

Doctors Outside the BoxIt ain’t brain surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Finger on the PulseTake a seat at the table, or you find yourself on the menu. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

HSAG VistasCulture matters: New Medicare initiative promotes culturally and linguistically appropriate services . . . . . . . 32

Maximum casualties...................................................................................................6

A tocsin for an Arizona statewide medical disaster plan .....................................8

The Medical Reserve Corps of Southern Arizona (MRCSA)...............................10

Community-based national preparedness ...........................................................12

Preparing your office for an infectious disease emergency ..............................14

The role of physicians in disaster response .........................................................16

What physicians should know about radiologic monitoring .............................18

The role of amateur radio in disasters..................................................................20

The Rural/Metro Fire Department Radiological Monitoring Program..............22

AHCCCS ABC’sMedicare Part D and, also, recoupment of health plan payments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

PerspectiveMedicine has become flat . . . . . . . . . . . . . . . . . . . . . . . . . 38

Arizona Innovations in Patient SafetyDefining the problem and implementing ‘sideways’ solutions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Guest ColumnReducing the uninsured in Arizona. . . . . . . . . . . . . . . . . . 42

Medicine Around Arizona . . . . . . . . . . . . . . . . . . . . . . . . 44

Calendar of Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Classifieds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

Inside Every Edition


Tucson, doctors were actually turnedaway when they arrived at the con-vention center, offering their servic-es. As it turns out, the state andcounties decided they didn’t need

them. The victims arriving here, forthe most part, weren’t in need ofongoing medical care. They weretriaged by the few health careproviders they obtained from areahospitals. Ultimately, the greatestneed was to find them temporaryhousing, which was found.

So, we dodged a bullet. The needwas not great. Yet, even though theprocess ran smoothly, it was hard toknow who was in charge. InPhoenix, the Arizona Departmentof Health Services worked withlocal area hospitals to comprisemedical teams to treat evacuees. InTucson, it was the Pima CountyHealth Department.

The message to the medical commu-nity from all of this was clear—we’ve got this under control. We’llcall you if we need you. But, the

Hurricane Katrina shook ournation—literally in the Gulf Coastregion—and glaringly pointed outjust how unprepared our nation isfor a disaster. Many days after thewinds, rain and floodsdevastated thousands ofmiles of coastal land,victims began to be relo-cated to nearby states,including Arizona,where volunteers waitedwith open arms.

Among those volunteerswere hundreds of ourstate’s physicians, whoresponded to a call forhelp from the ArizonaMedical Association. Utilizing a spe-cial web site, that was hastily pulledtogether, doctors from all over

Arizona signedon to do whatthey could for

those displacedLouisianansand

Mississippiansthat were headed

our way.

But, the doctors’phones never

rang. Theirpagers never

buzzed. In

By Leonard F. Ditmanson, MD

We were ready, but were we needed?reality is this was really small pota-toes. The total number of evacueeswho came here didn’t even total1,000. And, state officials had days,if not weeks, to prepare for this

small onslaught of mini-mally injured victims.

The obvious question is,are we, in Arizona, reallyready? Since 9/11, the adhoc Public HealthCommittee of theArizona MedicalAssociation has grappledwith that very questionand what the role of thein-the-trenches physicianwill be. We’ve had count-

less presentations and discussionswith state officials about this topic,but still are unclear about whatplans are in place and what every-one’s role will be.

No one denies the fact that when,not if, a disaster occurs, many, manypeople will be calling their doctorsor showing up at their offices, won-dering what to do. And, what willwe tell them? What is the plan?

Sooner, not later, this needs to beclearly defined. The ad hoc PublicHealth Committee will continue tohammer away at this issue until weget some answers. See some plans.Know our role.

We will be ready. And, I know wewill be needed.

Dr. Ditmanson is an internist practic-

ing in Tucson. He is president of the

Arizona Medical Association.

In Tucson, doctors were actually

turned away when they arrived at the

convention center, offering their services.

As it turns out, the state and counties

decided they didn’t need them.


Intr

oduc

tion

ease; an electromagnetic pulse that shuts downthe electric grid and destroys essential electronicinfrastructure; and the use of radiologic disper-sal devices (“dirty bombs”) or nuclear weapons.

Modern technology has magnified the biologicthreat—with air travel, more world trade, just-in-time inventories of essential supplies, andbioengineering. Much of the national prepared-ness thrust is directed toward improving vaccineproduction and stockpiling drugs. But the pri-vate doctor is basically left with InfectionControl 101, as outlined by Dr. Peter Kelly.

Computers and the Internet place the world’sknowledge resources at our fingertips—provid-ing that they work. Even if the power is on, theInternet does not have infinite capacity. If hun-dreds of millions try to access information all atonce, the system could freeze. The most robustform of communication is still radio. JoeThompson writes about the indispensable roleof the ham radio operators. ArMA Past PresidentDr. Earl Baker recognizes the importance of hav-ing a battery-powered or mechanically poweredradio. You should protect one by wrapping it ininsulating material and putting it in a metal con-tainer (a Faraday cage). But Tucson radio trans-mitters are not EMP hardened. Do you have ashort-wave radio or a line-of-sight ham radio?

In the 1980s, Federal Emergency ManagementAgency (FEMA) Director Julius Bectonremarked that “all hazards” preparedness hadcome to mean “all hazards but one.” The UnitedStates is still in a massive state of denial aboutthe possible use of one or more nuclear weaponson American soil, despite the chilling news fromIran, North Korea, Pakistan, and other places.General Becton made a valiant effort to revivecivil defense. But in the 1990s, FEMA’s Office ofCivil Defense was eliminated, the nationwideradiologic monitoring system was discontinued,

The intention of terrorists is to

produce maximum casualties and

maximum terror and disruption.

The result – intended or not – of

complacency, ignorance, and lack

of preparedness is to help

terrorists succeed.

Since 2001, we have had a massive bureaucracycalled the Department of Homeland Security;billions of earmarked expenditures; and possi-bly some improvements in our ability torespond to natural disasters and epidemics. Butin many ways, our ability to survive the reallybig threats has deteriorated. We have a long wayto go to reach the capacity we had in the 1960s.Fortunately, it is possible to prepare ourselves,virtually overnight, to save millions—if we havethe will to do so.

Pima County Medical Society ExecutiveDirector Steve Nash provides some historicalbackground on the vanishing role of physicians,especially office-based physicians, in the emer-gency response system. Former VirginiaGovernor James Gilmore gives a national per-spective on preparedness. Dr. Vincent Fulginitidetails local efforts to form volunteer MedicalReserve Corps to augment the capacity of pro-fessional responders. One big obstacle they havepartially overcome is tort liability. Terrorists pro-vide the explosives, and the plaintiff’s bar andour own courts put a roadblock between victimsand potential rescuers.

The really big threats that could destroy our civ-ilization include bioterrorism or pandemic dis-

By Jane M. Orient, MD

Maximum casualties


and states were ordered to dispose of the instrumentsthat had been maintained and calibrated for decades, asengineer Philip Smith explains in his primer on radio-logic monitoring.

The US government “plan” for dealing with nuclear dis-aster is to whisk important government officials off tohardened bunkers and tell the public that “you’re onyour own.” Radio is now running PSAs that featurechildish voices asking about the family plan, such as“Should I go to the neighbors’ if you’re not home?” Sofar, I’ve heard nothing about what to do if you see abright flash. My nephew’s wife, who was raised inBeijing, was taught to take cover immediately. Howabout your children?

The Department of Homeland Security is telling peoplethat they need to be able to take care of themselves for72 hours. If the emergency is another Hurricane Rita,FEMA can probably send in a truck with bottled waterby then. But what if five cities have been hit with anuclear weapon and FEMA has been obliterated?

Most Americans are terrified of any dose of radiation,however tiny, thanks to decades of hysteria mongering.They don’t even know that it is very easily measured.Firefighter Bob Thompson writes of the path-breakingprogram of Rural/Metro Fire Department to protect itspersonnel as well as the people they serve, deployingequipment that Smith developed, and setting standardsappropriate to a wartime environment. And, Dr. Baker issetting an example for private physicians to follow too.

The situation is not hopeless. Dedicated—and pre-scient—government scientists and engineers at OakRidge National Laboratory concluded in the 1950s thatthe federal government was not going to undertake aserious program of civil defense like that in Russia,Switzerland, Singapore, or China. Maybe the decision-makers wanted to keep Americans hostage to theMutual Assured Destruction ideology. Maybe they justthought the issue was a loser in the opinion polls. Butthe government did fund the work on expedient civildefense. We could use that knowledge to save millionsof lives even in the worst-case nuclear attack scenario.

It would not be a high-tech program. NukAlerts areingenious devices, and they should be as common assmoke detectors. But few of them exist now, comparedwith the need, and they can’t be manufactured withoutmonths of lead-time. However, an adequate instrumentcan be made in a few hours. Thousands have alreadydone it.

Rural/Metro Fire Department has one of these KearnyFallout Meters (KFMs) sealed in a paint can to keep itdry. You should have one too. If you don’t have aschoolchild to make you one, you can order a kit, or aready-made KFM. The prices are high—partly toencourage you to learn to make it yourself.

Then you need to know what to do with the reading.Depending on the dose-rate, you should either avoidpanic and continue doing your job—or take immediateaction to leave the area or shield yourself.

Of course, the official public shelter program was alsodiscontinued, but Kearny and coworkers provide expe-dient sheltering advice, along with instructions for mak-ing a KFM and information about nuclear weaponseffects. The “core shelter” could be constructed almostanywhere on short notice. It is shown in the civildefense DVDs produced by the Oregon Institute ofScience and Medicine, starring the late Cresson Kearnyhimself and volunteers. Kearny’s book Nuclear WarSurvival Skills is the bible on expedient, all-hazards civildefense, which FEMA once distributed to thousands ofstate and local emergency managers. NWSS covers thewhole gamut of survival needs, including ventilation,water purification and storage, food storage, andhygiene; it is not a dumbed-down duct-tape-and-plasticposter. All directions have been carefully field testedwith ordinary Americans. Download it now, while theInternet is up, and order a hard copy.

All physicians—all Americans actually—need a basicinsurance policy against the really big threats: someknowledge, a radiation meter, an EMP-protected radio, acopy of NWSS, and some basic supplies. Our govern-ment has developed the knowledge (and apparently hasforgotten it)—and left us on our own.

If we don’t prepare ourselves to confront the threat, are we collaborating with the terrrorist objective: maximum casualties?

Resources:

www.physiciansforcivildefense.org (includes the core shelter video and a link todownload NWSS)

www.nukalertnow.com (has a demo of how the NukAlert works and a photo ofRural/Metro firefighters)

www.nitro-pak.com (one source for ready-made KFMs)

http://oism.org/nwss/s73p1467.htm (order NWSS and/or a complete set of DVDs)

Dr. Orient is an internist. She is a Southern District Director ofArMA, chairman of the Public Health Committee of the PimaCounty Medical Society, member of the ArMA ad hoc PublicHealth Committee, and founder of Physicians for Civil Defense.She formerly lectured at the National Emergency Training Centerin Emmitsburg, MD.


A tocsin for an Arizona statewide medical disaster plan

By Earl J. Baker, MD

D o we face, post-9/11, anabsolute further threat from terroris-tic nuclear, biological and chemicalwarfare? Senator Sam Nunn, TedTurner and famed stock broker guruWarren Buffet have funded a“Nuclear Threat Initiative,” whichadds major private funds to aid gov-ernment agencies such as theInternational Atomic Energy Agency.They have also produced a docu-mentary film, “Last Best Chance,”available gratis viawww.nti.org/donate or (800) 336-0035. Thus, highly respected, patri-otic individuals have rallied to averta “not an ‘if’ but a ‘when’” disaster.

How should Arizona physicians so partner? First, for self and family, secure a 7-14 day shelter area (concrete whenavailable) and store liquids, foodsand antibiotics such as tetracyclineand Cipro (which, according to thearmed forces, has a 10-year shelflife), along with blankets, waste dis-posal items, and other essentials.

Second, physicians need access tocommunication ability—secure aGrundig or other “wind up” (notbattery dependant) short-wave radio(cost, less than $100), since allother non-wireless communicationis likely to be ineffective.

Third, provide for protection againstradioactive fallout from either a“dirty bomb” or even a nuclearexplosion. Both acute and chronicradiation health effects are covered

in an excellent review in the Journalof American College of Surgeons(January 2006, pp. 144-155).Physicians need to be able to meas-ure radiation levels with a devicesuch as a NukAlert radiation moni-tor/alarm, a small device that can fiton a key chain. The NukAlert, whichis “on” 24/7, emits a chirping soundwhen exposed to high radiation lev-els from 0.1 to >50 R/hr. TheNukAlert has a 10-year battery life.It is available fromwww.nukalert.com or (830) 672-8734, for $160 (with discounts forbulk orders).

For fallout from nuclear weapons,“for every seven-fold increase in time

after radiation detonation the expo-sure rate decreases by a factor of 10.”Measurement of time passage anddose intensity will facilitate decisionsabout emerging from shelter.

Education about bioterrorism—the“poor man’s atomic bomb”—is cru-cial. Anthrax is highly contagious,and spores are temperature resistant.The Arizona Medical Association adhoc Public Health Committee hasproduced an outline that should beposted in all office and hospital loca-tions. (See insert, “Key Resources—Bioterrorism”).

Finally, physicians need to beinvolved in community efforts. The


Arizona Medical Association, at theJune 2005 House of Delegates meet-ing, authorized partnership withthe Arizona Department of HealthServices and involved specialties.ArMA’s ad hoc Public HealthCommittee has initiated such anapproach, but the major difficultyremains the lack of a statewide,coordinated, topographic-specific

written plan to establish chain ofcommand, physician responsibility,use of manpower, area assignment,etc. The Arizona hospitals, police,and fire departments have a compa-rable program but, except for PimaCounty Medical Society, with theefforts of Drs. Bill Carrell andVincent Fulginiti and ExecutiveDirector Steve Nash, other physi-cian participation statewide hasbeen minimal.

The New Mexico legislature hasmandated a four to eight hour

In conclusion,individual physiciansshould establish a first-responder kit with a radiationmonitor and radio; prepare andstock the best possible shelter area;and participate in disaster self edu-cation including actual on-site exer-cises. The Arizona MedicalAssociation must implement anadvisory committee including multi-ple specialties such as emergencyand orthopedic physicians and part-ner with the state and county healthdepartments to establish a statewidewritten disaster response plan.

Arizona physicians (and dentists,veterinarians and nurses) have avocational obligation to implementsuch a statewide major disaster plan.Otherwise, we do not deserve therespect of our community, our chil-dren, or our grandchildren.

Dr. Baker is a past president of the

Arizona Medical Association. He is a

member of the ArMA ad hoc Public Health

Committee. He recently retired, after 14

years of service, as medical director of the

St. Vincent de Paul Medical and Dental

Clinic. Dr. Baker helped to found the clin-

ic, which has helped thousands in need of

medical and dental care.

course on nuclear, bio-logical, and chemical warfarefor all physicians seeking licenserenewal. This is facilitated by a certi-fied CD-ROM program, allowing forhome or office study.

On the positive side, the federallyfunded Maricopa Medical PhysicianReserve Core is a volunteer physi-

cian-directed, disaster educationprogram administered by theDepartment of Health and HumanServices and is scheduled to initiateclasses in early February 2006 atBanner Hospital. Contact RichardThomas, [email protected], 602-616-2327. Thisprogram is geared toward both ter-rorism and other year-round disas-ter occurrence. It has a potentialuse for other state areas and thuspartnership with the ArizonaMedical Association.

Physicians need to be able to measure radiation

levels with a device such as a NukAlert

radiation monitor/alarm, a small device

that can fit on a key chain.

The Medical Reserve Corps of Southern Arizona (MRCSA)

By Vincent Fulginiti, MD

A fter the events of 2001—the ter-rorist attack in New York City andthe anthrax episode—the federalgovernment decided that a robustsystem of volunteers was needed toaugment regular civic agencies suchas the police, fire services, andhealth care. Out of this planningdeveloped the concept of a corps ofvolunteer health care personnel whowould be recruited, trained, and reg-istered at a local level throughoutthe United States. Originally, theintent was to provide “surge” capac-ity to augment the regular healthcare system in the event of a disas-ter, particularly a bioterrorist attack.As more than 300 MRC units devel-oped across the United States,the purpose was expanded toallow for MRC personnel toassist local

health departments that might nothave the resources to accomplish allof their regular duties.

The unique aspect of the MRC con-cept is that each unit is developedbased on local needs, priorities, andorganization. This allows for greatflexibility in the organization of eachMRC and ensures that it will beresponsive to community needs andstructure in the event of a disaster.Some MRCs play a vital role in theircommunity’s public health activities,in areas where a robust public healthdepartment has not developed.Others are

more attuned to surge capacity train-ing and focus.

Approximately 50 interested personsin Tucson developed the first con-cept for a local MRC unit, appliedfor, and received a three-year grantto flesh out the concept. Difficultieswere encountered as this groupattempted to organize such a unit,one of the major factors being lackof provision for liability coverage ofthe volunteers. As a result, Drs. BillCarrell and myself were asked by thePima County Medical Society toassist the MRC to get beyond theearly planning stages. We acceptedthe responsibility and have accom-

plished the following:

10


1. Working with the governor’soffice, the attorney general, andRepresentative Amanda Aguirre(Yuma), along with interestedparties throughout the state, weassisted in the passage of H2599,which provides for immunityfrom, and coverage for, any suitbrought against a registered vol-unteer health professional, whileacting at the request of state orlocal authorities. The bill wassigned into effect by the gover-nor in November 2005.

2. We established the MRCSA as a501(c)(3) organization,enabling us to receive donationsas a means of sustaining theorganization.

3. We developed a mission andorganizational structure for theMRCSA consisting of an advisoryboard and task forces for medi-cine, nursing, phar-macy, mental health,allied health, envi-ronmental/publichealth and adminis-tration. We have suc-cessfully recruitedboard members and,most of the TaskForce leaders.

Advisory Board mem-bers include Dr. JohnSchaefer, former presi-dent of the Universityof Arizona; DonShropshire, former pres-ident and CEO ofTucson Medical Center;Alethea CaldwellMunsinger, former pres-ident of the Universityof Arizona MedicalCenter; Les Caid, chiefof the Rural/Metro FireDepartment; ScottIngram, program direc-

5. We are starting the active recruit-ment of volunteers in each of theTask Forces.

6. We are beginning to develop themultiple educational, training,and drill tasks for volunteers asthey become competent in theirnew roles.

There are two other Medical ReserveCorps in Arizona: one in MaricopaCounty, chaired by Dr. RichardThomas, and one in Yavapai County,chaired by Chris Mayo. It is likelythat additional MRCs may developin other parts of the state.

For further information and to considervolunteering, please send an email toeither Dr. Vincent Fulginiti([email protected]) or to Dr. WilliamCarrell ([email protected]).

tor, Volunteer Center of SouthernArizona; Dennis Douglas, director,and Michelle McDonald, MD, med-ical director, both of the PimaCounty Health Department; andChief Brad Olson of the Tucson FireDepartment.

Task Force leaders include RonSpark, MD, (Physicians); Dr. TedTong (Pharmacy); Mr. Bill Howe(Allied Health); Bernie Kuhr, MD,and Alan Levenson, MD, (MentalHealth); and Jim Justice, MD(Environmental/Public Health).

We are actively working on a simpli-fied, but precise, credentialing andregistrations system under H2599.

4. We have worked with the PimaCounty Health Department andthe city of Tucson to developclose, collaborative, and mutuallysupportive relationships.


Community-based national preparedness

By James Gilmore III and PJ Crowley

H urricane Katrina was the firstreal test of the homeland securityand national preparedness systemthe United States put in place fol-lowing 9/11. The federal responsewas, as President Bush said, unac-ceptable. The question is not who isto blame – the system did notfunction effectively at any level –but how do we make it betterbefore Mother Nature or terroriststest it again?

Katrina unveiled a preparednessand response system beset by con-fusion and under stress: agenciesstruggling to prepare for both nat-ural disasters and terrorism; anexpanded post-9/11 workloadwithout a larger workforce; organi-zational changes and personnelturnover that hindered intra- andinter-governmental communication;and flawed assumptions about theadequacy of homeland securityplanning and budgets.

Our ability to minimize the impactof a disaster is a key metric in thewar on terror.

To fix this, the president has sug-gested an expanded role for the mil-itary, even taking control of disasterresponse during a future majorcatastrophe. This would be a federaltop-down organization of homelandsecurity, preparedness and response.

It is the wrong approach. Federalizing or militarizing thesefunctions is unwanted by the statesand unnecessary. Rather than turn-

ing the existing system upside down,we should strengthen it from thebottom up. If we don’t believe stateand local authorities are prepared tohandle the next crisis, our nationalobjective should be to improvethem, not replace them.

There are many initiatives the federalgovernment can take – creating clearstandards, mandates, incentives andcross-sector synergies – to make pre-paredness and risk managementnational priorities. Our collectivesecurity should be the best we canachieve and not subject to the lowestcommon denominator.

However, over the long run, a com-munity-based system will be better,more sustainable, and consistentwith our values and civil liberties.We need to empower, not supplantstate and local officials, who will dothe bulk of the planning before thefact; be responsible for the first stageof any disaster; and put the commu-nity back together long after the fed-eral government moves on to the

next crisis. More importantly, whilethe federal government can urge theprivate sector to develop best prac-tices, community leadership is mostlikely to get individual companies toactually follow them.

The Department of HomelandSecurity (DHS) has recently reor-ganized itself to include a newDirectorate of EmergencyPreparedness and Response. Thepresident nominated Virginia’s toppreparedness official, George W.Foresman, to lead it—an excellentchoice. Undersecretary Foresmanwas sworn in by DHS SecretaryMichael Chertoff on January 20 ofthis year. As vice-chairman of theGilmore Commission, which recom-mended over 146 domestic responseimprovements prior to 9/11, Mr.Foresman understands the impor-tance of a national partnership wherestates, localities, and the federal gov-ernment cooperate rather than com-pete for control. We need – and donot yet have – such a partnership.

They must be prepared to handle

the first 48-72 hours on their own.

Disaster plans must be current,

realistic and regularly tested.


James Gilmore III is chairman of theNational Council on Readiness andPreparedness (www.NCORP.org) and governorof Virginia from 1998-2002.

First, it should preserve civil authority and reinforcecontinuity of government. Mayors and governors shouldbe in charge, with the federal government supportingthem. Cities and states need to take aggressive action themoment a hurricane is forecast or an incident occurs.They must be prepared to handle the first 48-72 hourson their own. Disaster plans must be current, realisticand regularly tested.

Second, federal support should be more efficient,transparent and flexible. Federal grants should be tai-lored to meet local needs and national standards. A one-size-fits-all strategy will fail. Grants should cover bothequipment and manpower costs. FEMA needs to mod-ernize its logistics system – not by creating its own, butby piggybacking off superior private sector expertise thatalready exists in every city and state.

Third, if military support is required, the NationalGuard should take the lead, not the active military.National Guardsmen come from local communities; theycan be activated quickly; and unlike federal troops, theycan perform law enforcement duties consistent withPosse Comitatus, the law that restricts the regular mili-tary from engaging in routine law enforcement. To theextent that the war in Iraq degraded its response toKatrina, the guard needs better equipment, a higherlevel of readiness and an updated command structure.

Fourth, while the existing EmergencyManagement Assistance Compact system of interstate

What should community-based preparedness look like?

mutual aid agreements worked well during Katrina, italso needs to work faster. One idea is to develop anational reserve of first responders, including certi-fied, trained and experienced fire, law enforcementand volunteer coordinators. Regional exercises wouldbe conducted regularly, with arrangements establishedregarding local reimbursement, liability and com-mand and control.

Finally, since the next terrorist attack is mostlikely to occur during a workday in a major commer-cial center and without warning, businesses need to befull participants. Every business location should have acorporate crisis response officer. Private sector repre-sentatives should be trained by, work directly with andexercise alongside local first responders. Companiesneed to be prepared to shelter employees in place untilthey can evacuate safely. Business continuity plansmust be developed in partnership with municipalities.Planning needs to integrate public and private assetsthat can help keep people informed, get them out ofharm’s way and sustain them until communities arefunctioning again.

Improved national preparedness will require biparti-sanship on Pennsylvania Avenue. We need a compre-hensive risk-based homeland security strategy backedby the necessary resources to prevent or recover fromall hazards, whether natural or terrorist. But the realaction must take place on Main Street where the nextground zero is likely to be; where the true first preven-ters and first responders are; where real change musttake place; and where that preparedness will makeAmericans truly safer.

PJ Crowley is a senior fellow and director ofnational defense and homeland security at theCenter for American Progress and was a specialassistant to President Clinton for national secu-rity affairs.



I n recent years, infectious diseaseshave shown a new face to practi-tioners. Locally occurring infectionsthat we are all accustomed to arestill present but are joined by newinfections not usually encounteredin ordinary practice.

The ease of international travel aidsthe spread of infections from remoteplaces to our community. Tworecent examples are West Nile Virusencephalitis and Severe AcuteRespiratory Syndrome (SARS). TheWest Nile Virus (WNV) arrived inNew York City from the Middle Eastin the summer of 1999. It estab-lished a focus of infection amongbirds and spread to humans viamosquito bites in the summermonths. By 2004, WNV had encom-passed nearly all of the continentalUnited States and Arizona had sev-eral hundred locally acquired cases.SARS emerged from China in 2003and, aided by air travel, caused epi-demics of pneumonia in Singapore,Taiwan, and Toronto. It is likely thatthe trend for new infections toemerge and spread to distant placeswill continue.

Another source of concern is delib-erate use of microorganisms asweapons of terror. DuringSeptember 2001, Bacillus anthraciswas spread via the US mail inWashington DC, New York City, andsouth Florida. Twenty-two cases ofanthrax occurred, and 11 of theinfected persons died. Federaloffices, the Congress, and the

Supreme Court all curtailed opera-tions temporarily. The individual(s)responsible for the attack remains atlarge today.

The infectious disease of themoment is avian influenza thatoriginated in Hong Kong andSoutheast Asia. Domestic poultry asfar west as Turkey is infected andapproximately 150 human caseshave occurred. The World HealthOrganization is concerned that theavian virus could adapt to humansand result in a pandemic.

Each of these examples illustratesthe need for practicing physicians toinform themselves and to prepare for

managing their offices during anoutbreak. Public health officials andour elected representatives have arole in preparing our communitiesand communicating the facts, butpublic opinion polls show thatAmericans will look to their ownphysicians for advice and guidancein the event of an emergency.

Getting informedAn encyclopedic knowledge of glob-al infections is not necessary for pre-paredness. Instead, access to com-pact, authoritative and timely infor-mation on diagnosis and treatmentis sufficient. Modern communicationvia the Internet puts just that sort ofmaterial at your fingertips. During

By Peter C. Kelly, MD, FACP

Useful preparedness web sites

• The Centers for Disease Control: www.cdc.gov Comprehensive sitefor information about specific diseases, and current communicabledisease issues.

• The Arizona Department of Health Services: www.azdhs.gov Homepage for the Department of Health Services. For more specific infor-mation on preparedness topics use www.azdhs.gov/phs/edc/edrp/.This site has links to the American Medical Association, theAmerican College of Physicians, the American Academy of Pediatricsand other professional associations.

• United States Department of Health and Human Services:http://www.hhs.gov/emergency/index.shtml. Comprehensive federalsite with links to Centers for Disease Control and the Department ofHomeland Security.

• United States Department of Homeland Security: www.ready.gov.Federal site providing preparedness information to citizens and busi-nesses on preparedness. Some of your patients may be familiar withthis site.


an epidemic or a bioterror attack,the Internet will be used to dissemi-nate current data on numbers ofcases, appropriate diagnostic tests,and effective therapy. All practicingphysicians should have Internetaccess and familiarity with using ahome or office computer. Box 1lists web sites that provide useful,up-to-date information for the prac-ticing doctor.

To use the sites effectively, visitthem prior to an emergency andbecome familiar with the formateach uses.

Preparing your office Medical offices can prepare bydeveloping a written emergencyplan that emphasizes infection con-trol techniques (Box 2) to protectyou, your family and the patientsyou serve.

Recent natural events such as hurri-canes have shown that some masscommunication facilities becomeinoperable at crucial times. Theoffice should have a battery ormechanically powered radio avail-able since radio is the last commu-nication technique to fail.

The Arizona Department of HealthServices has a desk-top flip chart,“Preventing Infections in theMedical Office,” that is availableupon request by contacting thedepartment at: Arizona Departmentof Health Services, 150 N. 18th Ave.,Suite 150, Phoenix, AZ 85007-3237;Att Leanne Allen or by email:[email protected].

Dr. Kelly is an allopathic (MD) physi-

cian specializing in infectious diseases. He

is an infectious disease specialist with the

Arizona Department of Health Services.

He is a member of the ArMA ad hoc

Public Health Committee.

The plan should include:

• Indentification of a leader whohas the trust and respect of the staff.

• How to report suspicious cases orunusual clusters of cases to yourlocal health department (See theArMA web site –www.azmedassn.org—for instruc-tions on reporting communicablediseases)

• How to notify your supervisor ofsuspicious cases

• How to distribute masks andgloves to staff in response to suspicious cases

• How to adjust office appoint-ments in response to a surge ofcalls from patients

• A communication strategy tokeep staff informed, minimizerumors and help staff cope with stress.

• Hand Hygiene: Wash your hands before andafter touching every patient. Wash using soapand water, or an alcohol-based hand rub. Glovesare not a substitute for hand washing. Washyour hands before putting on and after taking off gloves.

• Gloves and Masks:

Gloves: Wear gloves when you anticipate contactwith blood, body fluids, or any drainage. Disposeof gloves after each patient. Non-sterile disposablegloves are okay for most purposes.

Masks: Wear a disposable surgical mask when youare within three to six feet of a patient who iscoughing or sneezing. Offer a mask to the patientwho is coughing or sneezing.

• Respiratory Etiquette: Separate patient with respi-ratory symptoms from other patients by at least

three feet (arm’s length) where possible. In wait-ing and exam rooms, have tissues and handwashing material available.

• Needle Stick and Sharps Injury: Prevent injuryby wearing gloves while performing a blooddraw or giving an injection, using equipmentthat protects you from injury, and never recap-ping a used needle. Dispose of needles or othersharp instruments by placing them into a sharpscontainer. If you have a needle stick injury, fol-low the office protocol for management.

• Immunizations: The following immunizationsare recommended for office staff

Influenza vaccine every yearHepatitis B vaccineMeasles-mumps-rubella vaccine or proof of immunityVaricella vaccine or proof of immunity

Infection control procedures


The role of physicians in disaster response

I n December 1967, when bothlong distance and plane ticketsmeant something more substantialthan today, a phone rang inLeavenworth, Kansas. It was St.Mary’s Hospital in Tucson calling.

An Air Force F-4D Phantom jet hadcrashed into a crowded holidaysupermarket at Alvernon and 29thStreet. Homes behind weredestroyed as well.

We knew this.

For the first time in my young life,Tucson had made the “We nowinterrupt this show with an impor-tant news bulletin” on network tele-vision. We were visiting my grand-parents’ home for Christmas whenthe news flash came on aboutTucson, about home.

My dad was the neurosurgeonassigned to St. Mary’s in case of adisaster. The hospital knew exactlywhere he was and how to reachhim. St. Mary’s was in the processof purchasing tickets so he couldfly from Kansas City on a TWA707. Details of the disaster werestill sketchy, but major injurieswere expected.

Dad kissed us goodbye and left withUncle Herb. They were back twohours later. Fortunately, only fourpeople were killed and other casual-ties were light. He wasn’t neededafter all.

Skip forward to 2005. HurricaneKatrina victims were being flown toTucson. Although an 800-bed recep-tion center had been set up daysbefore, it seemed to be a state secretwhether community physicianswould be needed to help staff it. Noone knew whom to call. Thosephysicians who appeared at thereception center to volunteer wereturned away.

With all the money going into disas-ter preparedness since 9/11, should-n’t we have gotten more organizedsince 1967?

In many respects we are more organ-ized. The problem is the main com-ponent, physicians, are not part ofthe organization. They do not sit inleadership positions; they do not(except for the ED) participate indrills. The Pima County MedicalSociety (PCMS) is reduced to tellingphysicians that, if disaster strikes,they should stay near a phone orworking radio.

It was not always this way.

In the 1950s, government in Tucsonworked closely with physicians tocreate a civil defense response. Thismorphed into a purely private sys-tem wherein physicians wereassigned to a hospital in case of acitywide emergency. They knewwhere to report and were expectedto do so. Every physician had apager number for identification sothat even if communications were

down, local emergency broadcastscould ask doctor “761” to report to agiven location. After reporting to thehospitals, the pool of physicianscould be taken (if needed) to thescene of the disaster.

Physicians in Tucson eventually ranthe system. The medical society hadan Emergency Medical ServicesCommittee and a Disaster DrillCommittee. On May 4, 1980, themedical society staged the first city-wide disaster drill—a simulatedplane crash with 40 dead and 80burned and injured survivors.Physicians were the incident com-manders and worked well with air-port authorities, local police, fireofficials, and ambulance companies.

There are no straightforward expla-nations about how this system waslost. Some suggest that since wehad no disasters it was a case of“use it or lose it.” Others point tothe rise of paramedics, then EMTs,and the professionalism of otherfirst responders. Some point to alack of communication within theprofession, with the number of doc-tors in Tucson rising ten-foldbetween 1960 and 2000 with nocommon focal point. Hospitalpower has increased, and physiciantime demands have changed.

All these reasons are probably valid.But we need to do better.

There was a disaster drill in 2003 atthe airport. Police, firefighters, and

By Steve Nash


hospitals all participated, but notone doctor in 100 here knew thedrill took place.

PCMS has been part of the NationalDisaster Medical System since 1994.We joined the Metropolitan MedicalResponse System in 2002 and havehelped form the local MedicalReserve Corps. Whenever there is adisaster, 9/11 to Katrina, we are partof the discussion about what we cando better.

It has taken time, but we havefinally convinced most entitiesthat, as far as the physician seg-ment is concerned, we can’t justrely on call schedules. Many physi-cians don’t have hospital privileges;

others certainly don’t have a“home” hospital. Doctors are neverdrilled so they don’t know where toreport, when to show, where topark, or even who is in charge. Ourobject is not to take over the sys-tem again (which is unrealisticbecause all the money involved isflowing through city government)but to make sure the pieces are inplace for the next disaster.

One very bright success has beenthe Medical Reserve Corps.

It was begun in 2002 at the call ofthe federal government and placedunder the aegis of the Citizen CorpsCouncil. Community leaders whohad been trying to find a role forretired physicians since the early1990s began attending meetingswith health department officials.

unteer physicians the same liabilityprotection any state worker has oncethe state declares a disaster. Further,it covers physicians during training.Work is being done on what is need-ed to meet the state standards oncredentialing and training.

Our MRC is concentrating in threeareas: 1) to work with the firedepartment for deployment at amass casualty triage site, 2) to helpprimary care physicians, with orwithout hospital privileges, use theiroffices to meet the walking wound-ed surge, and 3) to determine theneed for volunteers at hospitals(especially for limited shifts on daysthree and four after a disaster).

Grant money is running out for theTucson MRC so it has incorporatedinto a 501(c)(3) entity. It will solicitfunds and build for a future wehope never comes.

Last summer, at the Arizona MedicalAssociation House of Delegatesmeeting, the PCMS delegation unan-imously supported a resolutionintroduced by the ArMA ad hocPublic Health Committee calling forArMA and physicians to take a lead-ership role in working in disasterplanning. The time for physicianleadership is now, in the un-sexyplanning stages. It has to be done.

Next time, we won’t get 87 peopleflown in from a flooded southerncity. We may have 8,700 criticallyinjured people from a Los Angelesearthquake, plus thousands of self-evacuated people pouring in.

You will be pulling the sled. Let’smake sure it is in as good a condi-tion as it can be and goes in a direc-tion that benefits us all.

Steve Nash is executive director of the

Pima County Medical Society.

The Tucson Volunteer Center won athree-year grant to staff and buildthe Tucson Medical Reserve Corps.

There were two main problems. Thefederal government did not givemuch guidance about what the MRCwas supposed to do or who wasgoing to cover the liability.

Pima County would cover liabilityfor health care workers called on tovolunteer provided it controlled thescope of work and directed things.The county found it could covermost prospective volunteersthrough blanket insurance policies.The exception: physicians. Eachdoctor had to be individually under-written. The county found covering

one volunteer doctor cost more thanblanket coverage for all other volun-teer workers!

The MRC used non-physician med-ical professionals and techniciansto create a “vaccine strike team”for use in bioterror and chemicalincidents. This strike team wassuccessfully drilled when Tucsonwas part of the NationalPharmaceutical Stockpile simula-tion in 2003. It has become anational model for other local med-ical reserve corps that are trying todetermine what role to play.

Another national model is how wesolved the liability issue in Arizona.

Under the leadership of WilliamCarrell, MD, and Vincent Fulginiti,MD, HB 2599 was passed last year,giving trained and credentialed vol-

With all the money going into disaster preparedness

since 9/11, shouldn’t we have gotten

more organized since 1967?


What physicians should know about radiologic monitoring

S uddenly, Americans are begin-ning to recognize that it is neces-sary to contemplate the use of ter-rorist nuclear or radiologicalweapons on American soil. Thegood news is that you will mostlikely survive such an attack. Thebad news is that you will wish youhad been better prepared.

Relatively simple measures andbasic training could enormouslyreduce casualties in such an event.These measures are not being taken.We are a nation in massive denial.

Following a radiological attack, thenation will turn to the medicalcommunity for direction and,unless things change, find confu-sion and disarray. You could findmobs of people converging on yourfacility or office – some injured,some contaminated, many in psy-chological distress. Are you pre-pared? How will you identify thosewho are contaminated and keepthem from contaminating others oryour facility? The national igno-rance of, and hysteria over, radia-tion could lead many to your facili-ty who are simply frightened. Howwill you greet them?

Radiation is conveniently measuredin Roentgens (R). A dose of 100 Rreceived within days is about thethreshold for clinical radiationsymptoms. The LD50 is around 400R to 600R. The intensity of radiation(dose rate) is measured in R/hr. If

you stay in a 1R/hr environment for4 days you may begin to experiencenausea, weakness, immune deficien-cies, and other problems. Oneinstrument popular with Departmentof Homeland Security (DHS) respon-

ders displays “H” for “Hot Zone” atany rate above 13 mR/hr(0.013R/hr)— a level that is some-times encountered on airline flights

and certainly not life threatening.How will your staff respond to anemergency worker telling them thatthe waiting room is a “Hot Zone?”Clearly some planning and trainingis demanded by the risks we face.

What about instrumentation?The Arizona Department of HealthServices has allocated funds forresponders and localities to pur-chase radiological instruments. The

By Philip Smith

Some basic requirements:• A plan for triage and patient flow that avoids cross-contamination

(entrance-only and exit-only portals)

• An authoritative person to manage the entry process (possibly armed)

• A decontamination area (showers, baby shampoo, baby wipes, disposalfacilities for clothing, a store of blankets and replacement coverings)

• A separate decontamination area for staff and responders

• A stock of potassium iodide

• Printed material to reassure patients about radiation and give themsomething to do

• Simple radiation measurement equipment and staff who understandtheir use (refurbished civil defense meters are appropriate)

• Dosimeters for staff

• Stored water, food, flashlights, batteries

• Communications equipment with backup power sources

• A plan for patient transport after release

• A plan to encourage your staff and increase the likelihood of theirreporting for and staying on duty


focus in instrument deployment hasbeen on interdiction rather thannuclear attack survival. Because thestandards established for theseinstruments demanded extreme sen-sitivity, stability, and accuracy, theinstruments are very expensive, andrelatively few are fielded. Worse,most of the instruments carried byresponders are so sensitive that theywill be overloaded and useless in apost nuclear detonation environ-ment. During the Cold War, nearlysix million high-level dose meters,rate meters, and survey meters weredistributed around the country. Thisstockpile was largely destroyedby the government, except fora small portion that wasauctioned off. These “sur-plus” CD instrumentscan be purchased atreasonable prices, butit is imperative thatthey be refurbishedand recalibratedbecause they are sev-eral decades old.

Although there is abewildering array ofinstruments to choosefrom, two basic types ofinstruments are appropriatefor medical facilities—theGeiger counter and the ion-chamber survey meter. Geiger coun-ters are very sensitive. If the Geigerprobe is placed in a container ofdiet salt (potassium chloride), itwill produce a frightening rapidclicking that can scare all but thewell informed. The Geiger counteris useful for decontaminationbecause it can help pinpoint thesource—fingernails, hair, nasal pas-sages, etc. It may be best to use ear-phones or simply watch the meterwhen using the instrument, as thepsychological impact of the soundcould cause unnecessary alarm. The

deploy these devices and can readilydetermine and advise, if specificradionuclides are involved, as in a“dirty bomb.” It is better to have aquantity of basic instruments thatcan be cross-checked than a veryfew sophisticated, expensivedevices. It is imperative that every-one on your staff has at least a basicunderstanding of radiation measure-ment, protection and decontamina-tion methods.

Much of the planning, training andpreparation required to effectivelyrespond to a nuclear emergency are

also appropriate for chemical andbiological threats. It is not suffi-

cient for the facility to have aplan. The plan must be

owned and understoodby everyone on yourstaff, even office work-ers, as they may bepressed into actionwith little warning.

If you fail to plan—you plan to fail.

References and resources:

Berger, ME; Leonard, RB; Ricks, RC;Wiley, AL; Lowry, PC; Flynn, DF.

Hospital Triage in the First 24 Hoursafter a Nuclear or Radiological Disaster.

Available online at:http://www.orau.gov/reacts/triage.pdf

Medical Management of Radiological CasualtiesHandbook. Military Medical Operations, ArmedForces Radiobiology Research Institute, Bethesda,Maryland 20889–5603, April 2003. Availableonline at: http://www.afrri.usuhs.mil/www/out-reach/pdf/2edmmrchandbook.pdf.

Kearny CH. Nuclear War Survival Skills. OregonInstitute of Science and Medicine. Expanded andupdated 1987. Available online at:http://www.oism.org/nwss/index.htm.

Philip Smith is president of Kno-Rad,

Inc. He has been involved in electronic

design since 1974, and is the co-inventor

of the NukAlert keychain radiation meter.

ion-chamber survey meter is usefulfor higher level measurements andfor identifying adequate shelter ifthe facility itself is in a high expo-sure area. A new type of device, theNukAlert®, is like a more slowlyresponding survey meter that, whilenot appropriate for decontaminationwork, is an inexpensive personalmonitor that could encourage work-ers to report for and stay on duty,especially if they know that theirfamilies can measure exposure rates

at home. The old standby “peepthrough” pen-style, quartz-fiberdosimeters are appropriate and inex-pensive; they should be worn byanyone dealing with contaminatedpeople or materials. The dosimetersshould be checked often.

It is not necessary for medical facili-ties to have the extremely expensiveanalyzers required to identify specif-ic isotopes. Government agencies



I magine the worst. Katrina, BandaAceh, 9/11. As a doctor, your mindgoes to people, mass casualties, andnever-ending work but, probably,not to communications. In each ofthese events, the communicationsinfrastructure was totally destroyed

or severely damaged. News tothe outside world was

crippled and, in

each case, amateur radio played anessential role in carrying the dread-ful news to ears that could bringhelp and relief. These were all dra-matic scenarios. Almost unimagin-able and impacting communicationscenters in ways that are reallybeyond the best-laid plans.

Time and again amateur radio hasbeen there when all else fails.

Perhaps you have a mental imageof a lone radio operator

(a “ham”) in someisolated setting des-perately hangingon, resolutely try-ing to contact theoutside world.

That image can bevalid. It certainly

was at Aceh and onthe Indian islands of

Andaman and Nicobar asthe tsunami obliterated

everything in sight. Butwhat followed soon after

was a marshaling of resourcesby highly competent hams

that were able to piece togetherradios and equipment to support

rescue operations until more helparrived. On Andaman, a group ofmainland hams had gone on a holi-day. In short order they were notonly getting the word out, but alsosupporting local first respondersfrom the medical, military, and lawenforcement communities. TheIndian Army quickly rushed themmore equipment knowing that it was

in competent hands. In Acehprovince, hams were the only meansof communications for extendedperiods of time.

Amateur radio is a hobby. Operatorsare tested and licensed by theFederal CommunicationsCommission to insure that theydon’t interfere with other radio serv-ices or cause harm, although experi-mentation is encouraged. Hamscome from all walks of life. Doctorsto be sure, engineers, nurses, policeand firemen, heads of state, cardi-nals, almost all astronauts, andRandal McCloy Jr. (the sole survivorof the West Virginia coal mining dis-aster in January) are a few of thetypes of people who hold a license.Our common interest is in radio andits advancement. We are also com-mitted to helping our fellow man inany way that radio can.

Hams have sought and found a realneed for their skills, knowledge, andequipment. In Pima County, we haveseveral organizations committed toemergency and disaster operations.All the hospitals in the Tucson areaprovide both equipment and spacefor ham teams to operate as back upcommunications resources in emer-gencies. We routinely drill and par-ticipate in emergency preparednessexercises with first responders of alltypes. We transmit triage and trans-portation information to each hospi-tal, as that data becomes available atan event. We are ready to provide

By Joe Thompson

each hospital with back-up commu-nications during communicationsoutages. In Pima County, throughour RACES group, we provide directcommunications support to theCounty Health Department in anever increasing number of ways.The Radio Amateur CivilEmergency Service is a federally reg-ulated concept that allows local gov-ernment bodies to use and sponsorour volunteer expertise and services.

The state of communications inAmerica is almost beyond compre-hension in its reach and capability.So why do we need to spend corpo-rate and public money and time on

amateur radio? There are severalanswers. The engineers who designcommercial and government andpublic service communications areoften also hams; our level of expert-ise tends to be quite high. Many ofus are good teachers and pass alongour knowledge to those in ourhobby who come from other fields,facilitating cross-pollination. Whilecommercial systems are extremelysophisticated and operate superblyunder normal circumstance, disas-ters are not normal. Earthquakes,hurricanes and tsunamis knockthings down. They cause system

amateurs have been using a ham-designed technology calledAutomatic Position ReportingSystem (APRS). You are just nowseeing it in commercial applications.It can have your cell phone auto-matically tell a dispatcher exactlywhere you are. APRS has been help-ing searchers keep track of eachother in desert and mountainoustopography as well as helping heli-copters find the searchers and theirpatients. It can also help policefind your stolen car or let the“OnStar” dispatcher get youmedical help.

There are some 14,000licensed hams in Arizona. InPima County there are morethan 3,000. We are volunteer-ing our time and resourcesconstantly to public service inmany ways. You will findus to be professional,knowledgeable, andready to serve.

Mr. Thompson is a

retired telecommunica-

tions CEO. A life-long

ham wannabe, he has

been licensed as

N3SRU since 1993. He

is active in emergency

communications in

Southern Arizona. He

can be reached via e-

mail at [email protected].

overloads that, in turn, cause systemcrashes. They lose power and theybreak. Amateur radio is, of course,subject to some of those same prob-lems—but we know how to main-tain our equipment, and we operateunder a concept of distributed archi-tecture. Equipment and people tendnot to be centralized in amateurradio, and so the single operatorsomewhere can function althoughwhole systems of equipment andpeople have crashed and burned.

Ambulances on the ground or inthe air have several frequenciesavailable for communication.Amateurs, by virtue of their broad

privileges, have entire bands allo-cated throughout the radio spec-trum. Thus, both short and longhaul communications can beobtained. This means that, regard-less of interference problems, wecan find some way to get through.

In the last 30 years, various civiliangroups, in cooperation with stateand local law enforcement, haveperformed some 10,000 search-and-rescue missions in the greaterTucson area. In nearly every mis-sion, amateur radio comes intoplay. For 10 or more years now,

The state of communications in America

is almost beyond comprehension

in its reach and capability.

So why do we need to spend

corporate and public money and time

on amateur radio?



The Rural/Metro Fire Department Radiological Monitoring Program

I n the summer of 2005, the RuralMetro Fire Department, operatingin Pima County, understood theneed for improved emergencyresponder preparedness in the lightof current threats. With this under-standing came the responsibility totrain and equip its responders,allowing them the tools necessaryto complete their mission.

That summer, the department took aclose look at its operations andmade the determination that therewere areas that could be improvedupon regarding its response to aWeapons of Mass Destruction event.With the bombings in London stillfresh in the public’s mind, thedepartment identified that a radio-logical response program and fur-ther operating guidelines were need-ed. This was to include equippingall front-line engine companies withradiological monitoring devices and

sending a large portion of its fire-fighters to Technical EmergencyResponse Training located inAnniston, Alabama, at the Center forDomestic Preparedness. As RuralMetro Fire Department is a privatelyowned fire department, and operatesunder a budget, with different con-straints than those of a municipalsystem, cost became an issue.

As detectors wereresearched, it wasfound that much of themore popular detectorscost thousands of dol-lars. A cheaper solutionwas needed. We identi-fied and contactedPhysicians for CivilDefense, an Arizona-based nonprofit organiza-tion. We accepted a donation of15 “NukAlert” monitors, which thedepartment immediately placed in

By Bob Thompson

If a radiological dispersal device (RDD)

or nuclear weapon is used in or

around Tucson, Rural Metro personnel

could help identify “hot” areas

and safe areas.


service on the front-line enginecompanies.

With this deployment, we neededto train our crews about potentialradiological sources and the use ofthe devices. The lead officer at eachstation was assigned the responsi-bility for educating all crewmem-bers on the proper monitoring withthe device. Then a crewmember

was designated to carry thedevice on his person each

24-hour shift, andaccount for it atcrew change; theyare easily clippedto the firefight-er’s belt.

limits given to the box below forRadiological Dose (Accumulative)and Radiological Dose rates (R/hr).

All “Nuke Alarms” requireBattalion Chief notification fordirection on medical evaluationand documentation.

If a radiological dispersal device(RDD) or nuclear weapon is used inor around Tucson, Rural Metro per-sonnel could help identify “hot”areas and safe areas. The ability toidentify areas where there is not animmediate radiation risk would bevery valuable in preventing panicand in allowing firefighters, andother first responders, to performtheir normal life-saving functions.

Mr. Thompson is a firefighter with

the Rural Metro Fire Department in

Tucson, Arizona.

Individual equipment numbers weredesignated to the devices foraccountability purposes.

Crews were to understand that the“NukAlert” is designed to alarmwhen a gamma or x-ray source isencountered. It was also understoodthat the device was not meant to beused as a source meter. The instru-ment emits a chirping sound whenexposed to radiation at a dose rate of0.1 R/hr, the approximate equivalentof 0.1 rem/hr, a dose rate that is sig-nificantly abnormal but not animmediate danger to personnel. Thenumber of chirps increases as theradiation intensity increases, on alogarithmic scale. A table printed onthe device itself indicates the dose-rate that corresponds to a certainnumber of chirps.

Based upon current and nationalguidelines, Rural Metro set the

Guidelines

10 rem for protection of major property

25 rem for life saving or protection of large populations

>25 rem for life saving or protection of large populations onlyby volunteers who understand the risk.

Contaminated Persons 2X BackgroundHotline 1-5 mR/hrTurn Back Dose (except for life saving) 10R/hr 7-8 chirps

Turn Back Dose Rate (even for saving lives) 200R/hr

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