Infection Control Today - 09/2003: BIOTERRORISM


By John Roark

How adequately a community manages a mass casualty event depends on the integration of the emergency medical services, including firefighters, police, ambulance services, medical personnel and hospitals.

Simply put, triage is the sorting of patients based on their medical needs. A standardized method of triaging in a mass casualty situation, called Simple Triage and Rapid Treatment (START), was developed by the Hoag Hospital and the Newport Beach, Calif. Fire Department to be used in the event of a multiple casualty incident (MCI). Many large cities use this system, which allows emergency medical technicians (EMTs) and paramedics to triage a patient at an MCI in 60 seconds or less.

The plan is based on three basic observations: assessment of the patient in terms of their airway, circulatory and neurologic status.1

The triage team must evaluate and place the patients into one of four categories:

  • Deceased (BLACK): Victim is dead/no care required
  • Immediate (RED): Immediate care/life threatening
  • Delayed (YELLOW): Urgent care/can delay up to one hour
  • Minor (GREEN): Delayed care/can delay up to three hours

One of the principals of triage is you need to be doing the greatest good for the greatest number of victims with the least depletion of resources, says Roy Alson, PhD, MD, associate professor of emergency medicine, Wake Forest Baptist Medical Center. During a disaster situation you may have patients who on a day-to-day basis could be saved in an emergency department. But during disaster, because you have many more victims and perhaps fewer resources, you might not be able to work on that patient.

You might have to bypass them and go to somebody who has a better chance of survival, or a better outcome. Thats a difficult thing for medical personnel to actually do. It runs contrary to our natural instinct.


Weve been proactive in preparation for disaster response for a number of years, says Linda Williams, assistant chief of medicine, North Little Rock Campus, Central Arkansas Veterans Healthcare System. When we drill during an exercise, its very important that we talk about interaction with the people who are going to be bringing the victims to us, and what they will have done in the field as well as how we will respond to them.

But being prepared goes well beyond ones own facility. One of the things that hospitals often do as they develop and test their disaster plan is they dont involve the local emergency management personnel, local fire, EMTs, and all the other players, says Alson. And they may not even involve the other hospitals in the community! Thats kind of foolish, because we dont operate in a vacuum. Everybody has to work together. I think that the steps are being taken. Theres definitely recognition that there is a problem. Theyre making great strides. But we have a ways to go.

Chemical Attack

In the event of a chemical attack or accidental chemical release, hospitals must have a knowledge of decontamination procedures. If you have contaminated patients, be it biological or chemical, intentional or accidental, they have to be decontaminated, says Alson. As a medical facility, you cannot afford to allow a contaminated patient inside the door, because then you lose the facility, and you lose the ability to treat the other patients. Decontamination has got to be an integral part of any kind of hazardous materials event. People have to train for that. You also have the security issues at your facility. They do continue even in an accident, because you dont want someone whos contaminated to run through looking for help and contaminate your whole hospital.

There are specific decontamination protocols when chemicals are involved, says Williams. For instance, our EMRT team is trained to respond for the release of chemical warfare agents. In our training we also learn how to deal with radiation events, industrial chemical events and biological events. The decontamination sequence can differ, the antidotes used differ, the type of response in the triage area vs. the hospital ER area after theyve been decontaminated differs depending on the agent thats involved.

You can adjust your decontamination approaches to what is used and how the patients are presented to you, continues Williams. For instance, receiving decontamination victims at a hospital would be vastly different than what you would do if you were going to the site in the field. 80 percent plus of contaminants can be removed by removing the clothing of the victim.

In dealing with the contaminated patient scenario, one of the things the hospital has to consider is being able to lock down, so that all access is through controlled areas, says Alson. And thats very difficult to do because its contrary to the image we want to project as medical facilities. But I believe it is absolutely necessary to do that to protect the functioning of the facility, or else you may very well lose the ability to care for any other patient, he reasons. The key issue of decontamination precludes all that, again bearing in mind that in an attack, your facility could very well become a target. In combat situations today, medics no longer wear the red crosses like they used to during the first World War, because it made them a target. Enemies quickly realized that if you shoot the medic, more people die. If Im a terrorist and I want to kill a lot of people, I set off a device and then I also do something to prevent the hospitals from treating them, and multiply my mortality.

The Worst Case Scenario

The ultimate worst case scenario would be if transportation were disrupted and you could not get available medical supplies and personnel to the victims, and you could not get the victims out from the area for medical treatment, theorizes Williams. In fact, I think thats what happened on a limited scale when the Twin Towers came down. You really could not get the victims, even the healthy ones, out in time. When you have limited egress or limited ability to enter an area, the victims are left without access to the medical resources that are available.

The worst case scenario would be when you have everything in place to be able to deliver the care, and theres no way to deliver it, continues Williams. Thats the worst case for a provider to know what to do, to have what you need to do it, and be unable to provide it. In fact, that can be one of the most psychologically devastating events for a provider. Because this is kind of the scenario: What if you gave a disaster and nobody came?

Having a large number of casualties and not having the supplies needed for a medical person is a horrible thing because you feel powerless, says Alson. But I would also argue that thats only part of that equation thats only looking at medical care. Things happen in disasters that are beyond just medicine, that can have significant impact on healthcare. For example, drinking water. If you have contaminated water you can have the spread of disease. It doesnt have to be a bioweapon, it can be infectious diarrhea. So the public health aspects of it are just as key. To me, the worst case scenario would be a disaster where Im unable to provide adequate water, shelter and food for the victims because of the event, which is potentially going to put in jeopardy their health and well-being. Even though they may not be patients now, they may potentially be.

Lessons Learned

The reality of terrorism was made real for Americans as the events of September 11 unfolded. It was a tremendous wakeup call, says Alson. The events of that day made the response to terrorism very personal for most Americans. Before that it was something they watched on TV. As a result of it I think we will see sustained support on the part of the public.

Since 9/11, many of the communities and hospitals have been stimulated to go back and examine their plans, says Williams. Many have conducted extensive reviews of their resources and liaison agreements. Many have done drills and have refined their procedures and protocols. There definitely is a heightened awareness.

Quite frankly, there are very few places in the world that could mobilize the assets and resources immediately available that the city of New York can put on, says Alson. Were talking about a city that has 15,000 fire fighters, 30,000 police officers. The amount of response personnel that they can mobilize is incredible. They had obviously learned some lessons from the first attack on the World Trade Center and they started to put them into place, but one of the things for us as a country is that we tend to be a little short-term. Disaster planning got very high for all of us right after the first attack.

Then other issues became more pressing. Some of the things that we had planned to do never happened. Thats not pointing fingers at anybody, its the reality of the world we work in.

The fact that in a very short period of time local assets were mobilized and moved, surrounding agencies came in to back the cities up, there was a lot of inter-agency support, federal assets were quickly moved its a reflection of the fact that the system that we have does work, Alson continues. Can we improve upon it? Yes. There are extensive reports that have made the analyses of the lessons learned from 9/11, and all of us are starting to improve on our response.


As we are focusing as a nation on response to terrorist events, we should not to lose sight of the fact that natural disasters, transportation accidents, chemical accidents happen every day, says Alson. Were actually more at risk in any one community from one of those than we are a terrorist event. Our training for the terrorist event, the principals we use for planning and training command, triage and the like, apply just as well to natural disaster. You can have the best terrorist response plan in the world for dealing with chemical or biological weapons, but if youre attaching it to a very poor community disaster plan for everything else, its not going to work. The keys to managing these events are planning in advance, training and that involves all the players training together and taking a team approach and realistically evaluating what you have done so that you use the exercise as a tool to assess: this has worked, this hasnt, we need to improve this, we forgot about this, and so forth. Then adjust what youre doing and train again. It takes time, it takes money and it takes commitment. And the worst part is youre doing all of this hoping that you never have to do it for real. The biggest thing I can do is to urge everybody to train and plan, taking an approach of not IF it happens here, but when.

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