EMT Terrorism Response and Disaster Management

Emergency Care and Transportation of the Sick and Injured, Twelfth Edition Chapter 41: Terrorism Response and Disaster Management Chapter 41 Terrorism Response and Disaster Management Unit Summary After students complete this chapter and the related course work, they will be able to describe what constitutes terrorism and the EMT’s response to terrorism, and they will be able to apply this knowledge. Additionally, the student will demonstrate an understanding of weapons of mass destruction (WMD) agents and countermeasures, as well as a fundamental knowledge of disaster management safety. National EMS Education Standard Competencies EMS Operations Knowledge of operational roles and responsibilities to ensure patient, public, and personnel safety. Mass-Casualty Incidents Due to Terrorism and Disaster • Risks and responsibilities of operating on the scene of a natural or man-made disaster. (pp 1528–1553) Knowledge Objectives 1. Define international terrorism and domestic terrorism; include examples of incidents that have been caused by each one. (p 1528) 2. Name four different types of goals that commonly motivate terrorist groups to carry out terrorist attacks. (p 1529) 3. Define weapon of mass destruction (WMD) and weapon of mass casualty (WMC); include examples of weapons considered WMDs. (p 1531) 4. Explain how the Department of Homeland Security (DHS) National Terrorism Advisory System (NTAS) relates to the actions and precautions EMTs must take while performing their daily activities. (pp 1532–1533) 5. Name the key observations EMTs must make on every call to determine the potential of a terrorist attack. (pp 1532–1533) 6. Explain the critical response actions related to establishing and reassessing scene safety, personnel protection, notification procedures, and establishing command EMTs must perform at a suspected terrorist event. (pp 1532–1535) 7. Discuss the history of chemical agents, their four main classifications, routes of exposure, effects on the patient, and patient care. (pp 1535–1542) 1 Emergency Care and Transportation of the Sick and Injured, Twelfth Edition Chapter 41: Terrorism Response and Disaster Management 8. List three categories of biologic agents, their routes of exposure, effects on the patient, and patient care. (pp 1542–1548) 9. Explain the role of EMS in relation to syndromic surveillance and points of distribution (PODS) during a biologic event. (pp 1548–1549) 10. Discuss the history of nuclear/radiologic devices, sources of radiologic materials and dispersal devices, medical management of patients, and protective measures EMTs must take during a nuclear/radiologic incident. (pp 1549–1552) 11. Describe the mechanisms of injury caused by incendiary and explosive devices; include the types and severity of wounds. (pp 1552–1553) Skills Objectives 1. Demonstrate the steps EMTs can take to establish and reassess scene safety based on a scenario of a terrorist event. (p 1535) 2. Demonstrate the steps EMTs can take for the management of a patient exposed to a chemical agent. (pp 1535–1542) 3. Demonstrate the use of the DuoDote Auto-Injector and/or the Antidote Treatment Nerve Agent Auto-Injector. (pp 1539–1540) Readings and Preparation Review all instructional materials including Emergency Care and Transportation of the Sick and Injured, Twelfth Edition, Chapter 41, and all related presentation support materials. Support Materials • Lecture PowerPoint presentation • Case Study PowerPoint presentation Enhancements • Direct students to visit Navigate. Content connections: In Chapter 40, Incident Management, the student was introduced to personal protective equipment (PPE) and the various types of suits and respiratory equipment used in a hazardous materials environment as well as some of the additional types of protections that can be offered in a WMD environment. Cultural considerations: Stress that terrorism is a political process, not necessarily a religious one; try to separate fact from the stereotypes. Also, emphasize that although it may be difficult because of ethical or moral reasons, when students are called on to treat a 2 Emergency Care and Transportation of the Sick and Injured, Twelfth Edition Chapter 41: Terrorism Response and Disaster Management suspected criminal or suspected terrorist, it is important that the patient receive the same care as other patients. Remind students that they are not the judge or the jury. Teaching Tips • Discuss the definition of terrorisim and cite examples of the following:    Domestic International Cyber • Discuss US and international terrorist acts from the past. • Ensure that students understand the main WMD types and subtypes:      Chemical Biologic Radiologic Nuclear Explosive Unit Activities Writing activities: Assign each student a chemical agent and have the students report back on its dispersal method, associated signs and symptoms, medical management, etc. Student presentations: Have students find and report on an article that details information about the Strategic National Stockpile and syndromic surveillance. Group activities: Facilitate a group discussion on the standard operating procedures and guidelines for a WMD response. Medical terminology review: This chapter has an extensive Vital Vocabulary section. Use the terms and definitions to create a matching activity. Pre-Lecture You are the Provider “You are the Provider” is a progressive case study that encourages critical thinking skills. Instructor Directions 1. Direct students to read the “You are the Provider” scenario found throughout Chapter 41. 2. You may wish to assign students to a partner or a group. Direct them to review the discussion questions at the end of the scenario and prepare a response to each 3 Emergency Care and Transportation of the Sick and Injured, Twelfth Edition Chapter 41: Terrorism Response and Disaster Management question. Facilitate a class dialogue centered on the discussion questions and the Patient Care Report. 3. You may also use this as an individual activity and ask students to turn in their comments on a separate piece of paper. Lecture I. Introduction A. It is possible that you may be called on to respond to a terrorist event during your career. 1. The question is not will terrorists strike again, but rather when and where they will strike. 2. You must be mentally and physically prepared for the possibility of a terrorist event. B. It is difficult to plan and anticipate a response to many terrorist events, yet there are several key principles that apply to every response. II. What Is Terrorism? A. Terrorist forces have been at work since early civilizations. 1. The US Department of Justice defines both international terrorism and domestic terrorism with these points: a. Involves violent acts or acts dangerous to human life that violate federal or state law b. Appears to be intended (i) to intimidate or coerce a civilian population; (ii) to influence the policy of a government by intimidation or coercion; or (iii) to affect the conduct of a government by mass destruction, assassination, or kidnapping 2. One difference between the two is location. a. International terrorism occurs primarily outside the territorial jurisdiction of the United States. b. Domestic terrorism occurs primarily within the territorial jurisdiction of the United States. 3. Modern-day terrorism is common in the Middle East, where terrorist groups frequently attack civilian populations. 4. In the United States, domestic terrorists have carried out multiple attacks. B. Only a small percentage of groups actually turn toward terrorism as a means to achieve their goals. 1. Religious extremist groups/doomsday cults 4 Emergency Care and Transportation of the Sick and Injured, Twelfth Edition Chapter 41: Terrorism Response and Disaster Management 2. Extremist political groups 3. Cyber terrorists 4. Single-issue groups III. Active Shooter Events A. An alarming new trend in domestic terrorism involves the concept of the lone wolf terrorist attack. 1. This has become a frequent threat in the United States. 2. The National Security Critical Issue Task Force defines lone wolf terrorism as “the deliberate creation and exploitation of fear through violence or threat of violence by a single actor who pursues political change linked to a formulated ideology, whether his own or that of a larger organization, and who does not receive orders, direction, or material support from outside sources.” 3. The motives of the lone wolf terrorist are not always clear. a. Attacks may target schools, music festivals, or shopping centers and are difficult to predict. B. Many lone wolf terrorist attacks involve firearms and not explosives. 1. This type of event is classified as an active shooter event. 2. These attacks have prompted discussion of gun laws, mental health, and education of the public and first responders on how to treat the casualties of active shooter events. a. The Hartford Consensus recommends that a response plan for active shooter response should include the acronym THREAT: Threat suppression, hemorrhage control, rapid extrication to safety, assessment by medical providers, and transport to definitive care. b. EMS crews may be equipped with ballistic vests and helmets so they can potentially be paired with law enforcement to assist with treatment and evacuation of injured people from an active scene. i. A key component to safely incorporating EMS crews with law enforcement teams who are moving forward into an active shooter scene is interagency training. IV. Weapons of Mass Destruction A. A weapon of mass destruction (WMD), or weapon of mass casualty (WMC), is any agent designed to bring about: 1. Mass death 2. Casualties 3. Massive damage to property and infrastructure (bridges, tunnels, airports, and seaports) 5 Emergency Care and Transportation of the Sick and Injured, Twelfth Edition Chapter 41: Terrorism Response and Disaster Management B. B-NICE and CBRNE are mnemonics to remember the kinds of weapons of mass destruction. 1. B-NICE: biologic, nuclear, incendiary, chemical, and explosive 2. CBRNE: chemical, biologic, radiologic, nuclear, and explosive C. To date, the preferred WMD for terrorists has been explosive devices. 1. WMDs are relatively easy to obtain or create and are specifically geared toward killing large numbers of people. D. Chemical terrorism/warfare 1. Chemical agents are manufactured substances that can have devastating effects on living organisms. 2. They can be produced in liquid, powder, or vapor form depending on the desired route of exposure and dissemination technique. 3. These agents consist of the following types: a. Vesicants (blister agents) b. Respiratory agents (choking agents) c. Nerve agents d. Metabolic agents (cyanides) E. Biologic terrorism/warfare 1. Biologic agents are organisms that cause disease. 2. Generally found in nature; for terrorist use, however, they are cultivated, synthesized, and mutated in a laboratory. 3. Weaponization of biologic agents is performed to artificially maximize the target population’s exposure to the germ. 4. The primary types are: a. Viruses b. Bacteria c. Toxins F. Nuclear/radiologic terrorism 1. There have been only two publicly known incidents involving the use of a nuclear device. a. Hiroshima and Nagasaki 2. It is possible for a terrorist to secure radioactive materials or waste to perpetrate an act of terror. a. These materials are far easier for a determined terrorist to acquire and require less expertise to use. b. “Dirty bombs” can cause widespread panic and civil disturbances. V. EMT Response to Terrorism 6 Emergency Care and Transportation of the Sick and Injured, Twelfth Edition Chapter 41: Terrorism Response and Disaster Management A. When you respond to a terrorist event, the basic foundations of patient care remain the same. 1. However, the treatment can and will vary. 2. Always remember situational awareness. B. Recognizing a terrorist event (indicators) 1. The planning of most acts of terror is covert, which means that the public safety community generally has no prior knowledge of the time, location, or nature of the attack. a. You must constantly be aware of your surroundings and understand the possible risks for terrorism. b. You must know the current threat level issued by the federal government through the Department of Homeland Security (DHS). 2. In April 2011, the color-coded Homeland Security Advisory System was replaced by the National Terrorism Advisory System (NTAS). a. Alerts from the NTAS contain a summary of the threat and the actions that first responders, government agencies, and the public can take to maintain safety. 3. Make sure you are aware of information sent out by the advisory system at the start of your workday. 4. On every call, make the following observations: a. Type of location b. Type of call c. Number of patients d. Victims’ statements e. Preincident indicators C. Response actions 1. Scene safety a. Remember to stage your vehicle a safe distance from the incident. b. Wait for law enforcement personnel to advise you that the scene has been made secure. c. If you have any doubt that it may not be safe, do not enter. d. The best location for staging is upwind and uphill from the incident. e. Remember the following rules: i. Failure to park your vehicle at a safe location can place you and your partner in danger. ii. If your vehicle is blocked in by other emergency vehicles or damaged by a secondary device (or event), you will be unable to provide victims with transportation or escape yourself. f. Secondary device i. Additional explosives that are set to explode after the initial bomb 7 Emergency Care and Transportation of the Sick and Injured, Twelfth Edition Chapter 41: Terrorism Response and Disaster Management ii. Intended primarily to injure responders and to secure media coverage iii. May include various types of electronic equipment such as cell phones or pagers 2. Responder safety (personnel protection) a. The best form of protection is preventing yourself from coming into contact with the agent. b. The greatest threats are contamination and cross-contamination. 3. Notification procedures a. Notify the dispatcher when you suspect a terrorist or WMD. b. Inform dispatch of: i. ii. iii. iv. The nature of the event Any additional resources that may be required The estimated number of patients The upwind route of approach or optimal route of approach c. It is extremely important to establish a staging area, where other units will converge. d. Trained responders in the proper protective equipment are the only persons equipped to handle the WMD incident. e. Keep in mind that there may be more than one type of device or agent present. 4. Establishing command a. As the first provider on scene, the EMT may need to establish command until additional personnel arrive. b. You and other EMTs may function as: i. ii. iii. iv. v. vi. Medical branch directors Triage supervisors Treatment supervisors Transportation supervisors Logistic officers Command and general staff c. If the initial incident command system (ICS) is already in place, immediately seek out the medical staging officer to receive your assignment. 5. Reassessing scene safety a. Constantly assess and reassess the scene for safety. b. Important component of situational awareness VI. Chemical Agents A. Chemical agents are liquids or gases that are dispersed to kill or injure. 1. The characteristics of an agent can be described as liquid, gas, or solid material. 2. Persistent or nonvolatile agents can remain on a surface for long periods, usually longer than 24 hours. 8 Emergency Care and Transportation of the Sick and Injured, Twelfth Edition Chapter 41: Terrorism Response and Disaster Management 3. Nonpersistent or volatile agents evaporate rapidly when left on a surface in the optimal temperature range. 4. Route of exposure is a term used to describe how the agent most effectively enters the body. a. Agents with a vapor hazard enter the body through the respiratory tract in the form of vapors. b. Agents with a contact hazard (or skin hazard) give off very little vapor or no vapors and enter the body through the skin. B. Vesicants (blister agents) 1. The primary route of exposure of blister agents, or vesicants, is the skin (contact). 2. However, if vesicants are left on the skin or clothing long enough, they produce vapors that can enter the respiratory tract. 3. Cause burnlike blisters to form on the victim’s skin and in the respiratory tract. 4. The vesicant agents consist of: a. Sulfur mustard (H) b. Lewisite (L) c. Phosgene oxime (CX) 5. The vesicants usually cause the most damage to damp or moist areas of the body, such as the armpits, groin, and respiratory tract. 6. Signs of vesicant exposure on the skin a. Skin irritation, burning, and reddening b. Immediate, intense skin pain (L and CX) c. Formation of large blisters d. Gray discoloration of skin (L and CX) e. Swollen and closed or irritated eyes f. Permanent eye injury 7. Signs and symptoms if vapors were inhaled a. Hoarseness and stridor b. Severe cough c. Hemoptysis d. Severe dyspnea 8. Sulfur mustard (H) is a brown-yellow oily substance that is generally considered very persistent. a. As the agent is absorbed into the skin, it begins an irreversible process of damage to the cells. b. Mustard is considered a mutagen, which means that it mutates, damages, and changes the structures of cells. c. The patient will experience a progressive reddening of the affected area, which will gradually develop into large blisters. 9 Emergency Care and Transportation of the Sick and Injured, Twelfth Edition Chapter 41: Terrorism Response and Disaster Management d. Mustard also attacks vulnerable cells within the bone marrow and depletes the body’s ability to reproduce white blood cells. e. Sulfur mustard vapors can be inhaled, creating upper and lower airway compromise. 9. Lewisite and phosgene oxime produce blister wounds very similar to those caused by mustard. a. Produce immediate intense pain and discomfort when contact is made. b. The patient may have a gray discoloration at the contaminated site. 10. Vesicant agent treatment a. There are no antidotes for mustard gas or CX. b. British anti-lewisite is the antidote for agent L. c. If any agent is inhaled, the patient may require prompt airway support as soon as decontamination is completed. C. Pulmonary agents (choking agents) 1. Gases that cause immediate harm to persons exposed to them. a. Includes chlorine (Cl) and phosgene b. They produce respiratory-related symptoms such as dyspnea and tachypnea. 2. The primary route of exposure is through the respiratory tract, which makes them an inhalation or vapor hazard. 3. Once inside the lungs, they damage the lung tissue and fluid leaks into the lungs. 4. Pulmonary edema develops, resulting in difficulty breathing because of severely impaired gas exchange. 5. Chlorine (Cl) was the first chemical agent ever used in warfare. a. Has a distinct odor of bleach and creates a green haze b. Initially it produces upper airway irritation and a choking sensation. c. Signs and symptoms i. ii. iii. iv. Shortness of breath Tightness in chest Hoarseness and stridor Gasping and coughing d. With serious exposures, patients may experience pulmonary edema, complete airway constriction, and death. 6. Phosgene has been produced for chemical warfare and is a product of combustion such as might be produced in a fire. a. A very potent agent that has a delayed onset of symptoms, usually hours b. The odor produced by the chemical is similar to that of freshly mown grass or hay. i. The result is that much more of the gas may enter the body unnoticed. c. Signs and symptoms of mild exposure: i. Nausea 10 Emergency Care and Transportation of the Sick and Injured, Twelfth Edition Chapter 41: Terrorism Response and Disaster Management ii. Tightness in chest iii. Severe cough iv. Dyspnea on exertion d. Pulmonary edema may be so severe that the patient continually coughs up white or pink-tinged fluid. e. A severe exposure produces such large amounts of fluid in the lungs that the patient may actually become hypovolemic and subsequently hypotensive. 7. Pulmonary agent treatment a. Remove the patient from the contaminated atmosphere. b. Aggressive airway management c. Do not allow the patient to be active. d. There are no antidotes. D. Nerve agents 1. Among the deadliest chemicals developed. a. Classified as WMDs b. Not readily available to the general public c. Extremely toxic and rapidly fatal with any route of exposure 2. Can cause cardiac arrest within seconds to minutes of exposure 3. A class of chemical called organophosphates, which are found in household bug sprays, agricultural pesticides, and some industrial chemicals, though at much lower strengths then in the weaponized form a. Organophosphates block an essential enzyme in the nervous system, causing the body’s organs to become overstimulated and burn out. 4. G agents came from the early nerve agents, the G series. a. Sarin (GB) is a highly volatile colorless and odorless liquid. i. LD50 (the standard measurement that represents the amount that will kill 50% of a population exposed to this level) of about 1 drop ii. Especially dangerous in enclosed environments iii. When it comes in contact with the skin, it is quickly absorbed and evaporates. iv. When it is on clothing, it has the effect of off-gassing. b. Soman (GD) is twice as persistent as sarin and five times as lethal. i. Has a fruity odor and generally has no color ii. A contact and an inhalation hazard iii. A unique additive in GD causes it to bind to the cells that it attacks faster than any other agent. c. Tabun (GA) is approximately half as lethal as sarin and 36 times more persistent. i. Has a fruity smell and an appearance similar to sarin ii. It is a contact and an inhalation hazard. d. V agent (VX) is a clear, oily agent that has no odor and looks like baby oil.