Emergency Response to Terrorism TC: Emergency Medical Services

1. Emergency Response to TerrorismTC: Emergency Medical Services Unit 4: Patient Care Part B

2. Physiological Effects B - Biological N - Nuclear I - Incendiary C - Chemical E - Explosives

3. Nuclear/Radioactive Devices • Four possibilities • Radioactive decay • Types of ionizing radiation • Alpha, Beta, Gamma • Units of measure • Scene control considerations

4. Sample Exposure Limits RAD = REM (for our purposes) mREM = millirem = 1/1,000 of a REM Natural background radiation - 1-year dose 300 mREM Flight from LA to Paris 4.8 mREM Barium enema 8,000 mREM Smoking 1.5 packs per day - 1-year dose 8,000 mREM Heart catheterization 45,000 mREM Mild Acute Radiation Syndrome 200,000 mREM LD50 for irradiation 450,000 mREM

5. Acute Radiation Syndrome (ARS) • Effects of radiation • Blood effects starting at 150 REM • Gastrointestinal effects starting at 500 REM • CNS effects starting at 1,000 REM • Personal protection • Time, Distance & Shielding • Use of personal protective equipment

6. Physiological Effects B - Biological N - Nuclear I - Incendiary C - Chemical E - Explosives

7. Incendiary Devices • Consider materials used • Fuels • Phosphorus • Hypergolic mixtures • Thermal burn treatment • Maintain body temperature • Follow local burn treatment protocols

8. Physiological Effects B - Biological N - Nuclear I - Incendiary C - Chemical E - Explosives

9. Chemical Agents Overview • Classifications • Choking agents • Vesicating agents • Cyanides (blood agents) • Nerve agents

10. Choking Agents: Physiological Effects • Respiratory structure • Particulate disposition • Respiratory irritants • Respiratory irritation • Non-cardiogenic pulmonary edema

12. Vesicating Agents • Vesicles • Oldest chem warfare agent • Signs & symptoms • Clinical effects • Personal protection • Treatment • Triage considerations

13. Cyanides • Description • Clinical effects • Symptoms • Protection • Treatment

14. Nerve Agents • Very toxic relatives of pesticides • Disrupt nerve impulses to muscles, glands & nerves • Not gases; generally oily liquids • Effect function of material used and method of dissemination related to whether victim is in enclosed or open space

15. Nerve Agent Vapor Pressure GA Tabun 0.07 mm/Hg GB Sarin 2.9 mm/Hg GD Soman <0.01 mm/Hg VX V-Agents 0.0007 mm/Hg

16. Nerve Agent Considerations • Tokyo sarin experience • Clinical effects • Protection • Signs & symptoms • Treatment

17. Activity 4.3 Determining Patient Care Considerations

18. Physiological Effects B - Biological N - Nuclear I - Incendiary C - Chemical E - Explosives

19. Explosive Weapons • The most commonly used • Types: high & low • Pressure effects • Primary & secondary injury effects • Crush syndrome • Treatment modalities • In-the-rubble management • Controversial interventions

20. Mass Patient Decontamination “Cleaning in Numbers”

21. Primary Considerations • Basic steps remain the same • Gross • Secondary • Tertiary • Patient care • Runoff control is of limited concern

22. Extent of Decontamination • Factors to secondary contamination risks • Physical state of agent • Water solubility • Vapor pressure • Mass decontamination systems

23. Crowd Emergency Decon • Various examples • 2-engine • 3-engine

24. Engine 14 Victims Engine 63 Crowd Emergency Decon

25. Engine 14 Victims Engine 63 Truck 673 Crowd Emergency Decon

26. Two-Corridor Mass Decon

27. Three-Corridor Mass Decon • Trailer positioned in center for non-ambulatory patients • Shower heads off both sides of trailer • Shower areas have privacy curtains • Males to one side • Females to other side

28. Accessories - Tents

29. Accessories - Stretchers

30. Accessories - Systems

31. Activity 4.4 Post Office Scenario (Part 2)

32. Post Office: Phase 1 • 1000 hours MONDAY • Your agency is dispatched to the local post office on an EMS call for a female with shortness of breath. The local police department also responds with 1 police car. While you are responding, your dispatcher notifies you that there are additional calls. Some of the callers are reporting a male victim.

33. Post Office: Phase 2 • 1005 hours MONDAY • Upon arrival you see approx. 15 people outside the main door to the post office coughing, tearing, & calling for help. Several are on their knees. As you put the vehicle in park, 5 people start running toward you calling for help. • The people report that there was a white cloud in the lobby & their eyes & skin started burning.

34. Post Office: Phase 3 • 1010 hours MONDAY • Law enforcement units are arriving to secure the outer perimeter and the high ground around the post office. Your EMS director has arrived and has formed a unified command with law enforcement and the fire department command officer.

35. Post Office: Phase 3 (cont.) • 1015 hours MONDAY (cont.) • Two additional ambulances have arrived and your EMS supervisor is currently serving as the Mass Casualty Branch director and has ordered you to assume position of treatment group leader. You are still presented with 15 patients generally complaining of burning eyes, respiratory irritation and coughing

36. Summary • Mainstays of patient care • Rescuer self-protection • Prevention of further exposure • Provide supportive care • Decon • BLS & ALS treatment • Transport • Transfer • Key recognition of terrorist event • Weapons present with specific patient injuries & system impacts: B-NICE