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

incidents perimeterhospitals~80%

Whelm ALLhealth care facilities

Worried-well1:5

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

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

Hospita