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  • Basic PrinciplesBasic Principles of of Hospital PreparednessPreparedness

    in Casein Case of a Terrorism CBRN Incidentof a Terrorism CBRN Incident


    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


    Cyanogen Chloride


    Hydrogen Cyanide








    Relative lethality in relation to chlorine (respiratory)

    What agents can be used for a terrorism urban attack?


    Choking Blood Blister Nerve



  • 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?


    Temperature(high = low persistency)(low = high persistency)

    Rain(hydrolysis of agents = reduces effectiveness)

    Atmospheric stability(inversion/lapse)

  • Epidemiological clues of a CBRN terrorism attack


    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


    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


    What is the real picture at the incident site?



    Less/Not affectedwill run to the

    incidents perimeterhospitals~80%

    Whelm ALLhealth care facilities



    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


    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


    SF: Available

    SF: Not AvailableGate control possible

    Gate control impossible

    PreparednessLevel of knowledgeObey instructions

    Motivation for assistance

  • Decontamination of casualties










    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


    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


    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 dont happen to placesDisaster happen to peopleDisaster can happen to us!

    Disaster dont happen to placesDisaster happen to peopleDisaster can happen to us!

  • Hospita