Hospital Emergency Response Training (HERT) for Mass Casualty Incidents (MCI) Train-the-Trainer Course Course Code: B461

Hospital Emergency Response Hospital Emergency Response Training (HERT) for Mass Casualty Training (HERT) for Mass Casualty Incidents (MCI) Train-the-Trainer Incidents (MCI) Train-the-Trainer

Course Course

Course Code: B461Course Code: B461

DHS/NTCDHS/NTC B461 CourseB461 Course 22

HERT FOR MCIHERT FOR MCI

Hospital Emergency Response Training (HERT) for Mass Hospital Emergency Response Training (HERT) for Mass Casualty Incidents (MCI) Train-the-Trainer, B461 CourseCasualty Incidents (MCI) Train-the-Trainer, B461 Course

Resident Offering at Noble Training Center, Anniston, Resident Offering at Noble Training Center, Anniston, AlabamaAlabama

4.0 Days4.0 Days Special offerings for hospital emergency departments, Special offerings for hospital emergency departments,

administration, and staff personnel administration, and staff personnel Prerequisites:Prerequisites:

IS-195, Basic ICSIS-195, Basic ICS IS-346, An Orientation to Hazardous Materials for Medical IS-346, An Orientation to Hazardous Materials for Medical

PersonnelPersonnel


What HERT for MCI is Not?What HERT for MCI is Not?

Not a HazMat Course. Need additional training under:Not a HazMat Course. Need additional training under: OSHA’s Hazardous Waste Operations and Emergency OSHA’s Hazardous Waste Operations and Emergency

Response, 29 CFR 1910.120, par (q), 1990Response, 29 CFR 1910.120, par (q), 1990 OSHA 3152 Hospital and Community Emergency Response – OSHA 3152 Hospital and Community Emergency Response –

What You Need to Know, 1997What You Need to Know, 1997 OSHA’s Best Practices for Hospital-Based First Receivers of OSHA’s Best Practices for Hospital-Based First Receivers of

Victims from Mass Casualty Incidents Involving Hazardous Victims from Mass Casualty Incidents Involving Hazardous Substance Releases, 2004Substance Releases, 2004

Department of Health and Human Services, CDC Department of Health and Human Services, CDC Recommendations for Civilian Communities Near Chemical Recommendations for Civilian Communities Near Chemical Weapons Depots: Guidelines for Medical Preparedness, 1995Weapons Depots: Guidelines for Medical Preparedness, 1995

USACHPPM, Technical Guide 275, PPE for Military MTF USACHPPM, Technical Guide 275, PPE for Military MTF Personnel Handling Casualties from WMD and Terrorist Events, Personnel Handling Casualties from WMD and Terrorist Events, 20032003


What HERT for MCI is Not? (Cont’d)What HERT for MCI is Not? (Cont’d)

Not a Hospital Emergency Incident Command System Not a Hospital Emergency Incident Command System (HEICS) Course:(HEICS) Course: HERT stresses HEICS as a valuable tool for hospitalsHERT stresses HEICS as a valuable tool for hospitals Recognizes all Hospital Incident Management Systems (HIMS)Recognizes all Hospital Incident Management Systems (HIMS) HERT emphasizes a hospital IMS during emergency responseHERT emphasizes a hospital IMS during emergency response HERT integrates its HIMS into all aspects of the courseHERT integrates its HIMS into all aspects of the course



Not a Weapons of Mass Destruction (WMD) Course:Not a Weapons of Mass Destruction (WMD) Course: HERT emphasizes the handling of patients contaminated with HERT emphasizes the handling of patients contaminated with

CBRNE agentsCBRNE agents Recognizes attendee’s prior training and skills concerning these Recognizes attendee’s prior training and skills concerning these

agentsagents Attendees should receive additional training on WMD Events Attendees should receive additional training on WMD Events

from ODPfrom ODP



Not a National Incident Management System (NIMS) Not a National Incident Management System (NIMS) Course:Course: HERT emphasizes the use of an incident management system HERT emphasizes the use of an incident management system

to comply with the NIMSto comply with the NIMS Recognizes attendee’s prior training in the NIMSRecognizes attendee’s prior training in the NIMS Has incorporated NIMS where it applies throughout the courseHas incorporated NIMS where it applies throughout the course Participants wanting additional training should enroll in FEMA’s Participants wanting additional training should enroll in FEMA’s

Online Courses in the NIMS:Online Courses in the NIMS:• IS 700 NIMS, An IntroductionIS 700 NIMS, An Introduction

• IS 800 NRP, An IntroductionIS 800 NRP, An Introduction

Unit OneUnit One

Course Introduction: Origin of the Course Introduction: Origin of the Incident Command System (ICS)Incident Command System (ICS)


ObjectivesObjectives

Review ICS as an incident management toolReview ICS as an incident management tool List uses of ICS in emergency managementList uses of ICS in emergency management Describe the history of ICSDescribe the history of ICS Discuss the evolution of HEICSDiscuss the evolution of HEICS Define basic HEICS structureDefine basic HEICS structure Review ICS organizational chartReview ICS organizational chart


Objectives (cont'd)Objectives (cont'd)

Develop an initial organizational structureDevelop an initial organizational structure List minimum staffing requirementsList minimum staffing requirements Prepare an incident briefingPrepare an incident briefing Participate in a planning meetingParticipate in a planning meeting Develop incident objectives and an Incident Action Plan Develop incident objectives and an Incident Action Plan

(IAP)(IAP) Identify appropriate uses of resourcesIdentify appropriate uses of resources


What is ICS?What is ICS?

The model incident management tool for:The model incident management tool for: Command, control, and coordination of an emergency Command, control, and coordination of an emergency

responseresponse Providing a means to coordinate efforts of individual Providing a means to coordinate efforts of individual

agenciesagencies Allowing agencies to work toward a common goal for Allowing agencies to work toward a common goal for

stabilizing an incidentstabilizing an incident Ensuring the protection of life, property, and the Ensuring the protection of life, property, and the

environmentenvironment


When is ICS Used?When is ICS Used?

Hazardous materials incidentsHazardous materials incidents Response to natural disastersResponse to natural disasters Fire and riot controlFire and riot control Incidents involving multiple casualties:Incidents involving multiple casualties:

Weapons of Mass DestructionWeapons of Mass Destruction Mass Casualty EventsMass Casualty Events

Wide-area search and rescue missionsWide-area search and rescue missions


History of ICSHistory of ICS Developed in the 1970s in response to major wild Developed in the 1970s in response to major wild

land fires in Southern Californialand fires in Southern California Allowed for collaboration to form the:Allowed for collaboration to form the:

Firefighting Resources of Southern California Organized Firefighting Resources of Southern California Organized for Potential Emergencies, or FIRESCOPEfor Potential Emergencies, or FIRESCOPE


History of ICS (cont'd)History of ICS (cont'd)

FIRESCOPE identified several recurring problems FIRESCOPE identified several recurring problems involving multi-agency responses, such as:involving multi-agency responses, such as: Nonstandard terminologyNonstandard terminology Lack of flexibility to expand or contract resources as Lack of flexibility to expand or contract resources as

requiredrequired Nonstandard and nonintegrated communicationsNonstandard and nonintegrated communications Lack of consolidated action plansLack of consolidated action plans Lack of designated facilitiesLack of designated facilities


History of ICS (cont'd)History of ICS (cont'd)

Efforts to address these difficulties resulted in the Efforts to address these difficulties resulted in the development of an ICS modeldevelopment of an ICS model

Success of ICS has resulted directly from applying:Success of ICS has resulted directly from applying: A command organizational structureA command organizational structure Key standardized management principlesKey standardized management principles


NIIMS versus NIMSNIIMS versus NIMS

NIIMS (existing):NIIMS (existing):

1.1. Incident Command System (ICS)Incident Command System (ICS)

2.2. TrainingTraining

3.3. Qualifications & CertificationQualifications & Certification

4.4. Publications ManagementPublications Management

5.5. Supporting TechnologySupporting Technology

NIMS (new):NIMS (new):

1.1. Command & Incident Command & Incident ManagementManagement

2.2. PreparednessPreparedness

3.3. Resource ManagementResource Management

4.4. Communications Information & Communications Information & Intelligence ManagementIntelligence Management

5.5. Science & Technology Science & Technology ManagementManagement


Hospital Emergency Incident Hospital Emergency Incident Command System (HEICS)Command System (HEICS)

Modeled after FIRESCOPEModeled after FIRESCOPE Early work by the Northern California Hospital CouncilEarly work by the Northern California Hospital Council California authorized a grant to Orange Country EMS California authorized a grant to Orange Country EMS

for HEICS Project 91/92for HEICS Project 91/92 Major rewrite of HEICS documents:Major rewrite of HEICS documents:

Now provide the current HEICS PlanNow provide the current HEICS Plan

HEICS considered a model for hospital incident HEICS considered a model for hospital incident management systemmanagement system


HEICS AttributesHEICS Attributes

HEICS attributes:HEICS attributes: Command, control, coordination, and intelligenceCommand, control, coordination, and intelligence

Functional incident management systemFunctional incident management system A dependable chain-of-commandA dependable chain-of-command Improved communications through common languageImproved communications through common language Flexibility in section (component) activationFlexibility in section (component) activation Prioritization of dutiesPrioritization of duties Adaptable to HazMat, WMD, and MCIAdaptable to HazMat, WMD, and MCI


HEICS Attributes (cont'd)HEICS Attributes (cont'd)

Organized documentation for improved financial recoveryOrganized documentation for improved financial recovery Facilitates effective mutual aid with:Facilitates effective mutual aid with:

Other hospitals, andOther hospitals, and AgenciesAgencies


Basic HEICS StructureBasic HEICS Structure

Basic units of structure:Basic units of structure: Incident CommanderIncident Commander Section ChiefsSection Chiefs DirectorsDirectors Unit LeadersUnit Leaders OfficersOfficers


ICS Organizational ChartICS Organizational Chart

Represents lines of authority and communicationsRepresents lines of authority and communications Command element (IC and staff)Command element (IC and staff) Four functional sections:Four functional sections:

Planning Planning OperationsOperations Logistics, and Logistics, and Finance/AdministrationFinance/Administration


ICS OrganizationICS Organization

IncidentIncidentCommandCommand

Finance/Finance/AdministrationAdministration

SectionSection

LogisticsLogisticsSectionSection

OperationsOperationsSectionSection

PlanningPlanningSectionSection


Incident CommanderIncident Commander Incident Commander (IC):Incident Commander (IC):

Defines the mission and ensures its completionDefines the mission and ensures its completion Has overall control of incident or emergency Has overall control of incident or emergency

responseresponse Can appoint a deputy commanderCan appoint a deputy commander


Command StaffCommand Staff

Safety OfficerSafety OfficerSafety OfficerSafety Officer

Liaison OfficerLiaison OfficerLiaison OfficerLiaison Officer

Public Information OfficerPublic Information OfficerPublic Information OfficerPublic Information Officer




Command Staff (cont'd)Command Staff (cont'd) Command Staff is:Command Staff is:

Public Information OfficerPublic Information Officer Liaison OfficerLiaison Officer Safety OfficerSafety Officer Officers can also have AssistantsOfficers can also have Assistants


General StaffGeneral Staff


Finance/Finance/AdministrationAdministration

SectionSection

LogisticsLogisticsSectionSection

OperationsOperationsSectionSection

PlanningPlanningSectionSection


Planning SectionPlanning Section Planning Section:Planning Section:

Determines and provides for the continuance of each Determines and provides for the continuance of each response objectiveresponse objective

Prompts and drives all Officers to develop:Prompts and drives all Officers to develop: Short-range action planningShort-range action planning Long-range action planningLong-range action planning

Responsible for preparing the IAPResponsible for preparing the IAP


Planning Section (cont'd)Planning Section (cont'd)

Planning SectionPlanning Section

Demobilization Unit

Demobilization Unit

Documentation Unit

Documentation Unit

Situation Unit

Situation Unit

Resource Unit

Resource Unit


Operations SectionOperations Section

Operations Section:Operations Section: Carries out the objectives to the best of the staff’s abilityCarries out the objectives to the best of the staff’s ability Oversees and directs all response operationsOversees and directs all response operations Determines needs and requests additional resourcesDetermines needs and requests additional resources


Operations Section (cont'd)Operations Section (cont'd)

StagingArea(s)

MedicalBranch

Rescue

BranchMulti-Casualty

BranchHazMat Group

Operations Section


Logistics SectionLogistics Section Logistics Section:Logistics Section:

Provides a hospitable environment and materials for the Provides a hospitable environment and materials for the overall objectivesoverall objectives

Ensures service and support for respondersEnsures service and support for responders


Logistics Section (cont'd)Logistics Section (cont'd)

Logistics Section

Service Branch Support Branch

Communications Unit

Food Unit

Medical Unit

Supply Unit

Ground Support Unit

Facilities Unit


Finance/Administration SectionFinance/Administration Section

Finance/Administration Section:Finance/Administration Section: Provides funding for present objectivesProvides funding for present objectives Stresses facility-wide documentation to Stresses facility-wide documentation to

maximize:maximize: Financial recovery, andFinancial recovery, and Reduction of future liabilityReduction of future liability


Finance/Administration Section Finance/Administration Section (cont'd)(cont'd)

Finance/Admin Section

Cost Unit

Compensation/Claims Unit

Procurement Unit

Time Unit


Future of the ICSFuture of the ICS Continues to expand throughout U.S.:Continues to expand throughout U.S.:

Law enforcementLaw enforcement Government agenciesGovernment agencies Hospitals and HCFHospitals and HCF

Will be revisited to ensure:Will be revisited to ensure: It remains relevant to response agencies, and It remains relevant to response agencies, and Current with standardized ICS modelsCurrent with standardized ICS models

Must be adaptable to include an ICS/UC structure for Must be adaptable to include an ICS/UC structure for HMI, MCI, and WMD eventsHMI, MCI, and WMD events

Should incorporate NIMS as adopted on March 1, 2004Should incorporate NIMS as adopted on March 1, 2004

Unit TwoUnit TwoHospital Incident Management Hospital Incident Management

System (HIMS)System (HIMS)



Describe Hospital Incident Management System for:Describe Hospital Incident Management System for: Planned & unplanned eventsPlanned & unplanned events Mass casualty incidentsMass casualty incidents HazMat incidentsHazMat incidents CBRNE eventsCBRNE events

Describe transfer of commandDescribe transfer of command


HIMS – Operations Section MembersHIMS – Operations Section Members

HIMS Operations Section could consist of:HIMS Operations Section could consist of: Operations Section ChiefOperations Section Chief Group/Division SupervisorsGroup/Division Supervisors

• CBRNE or HazMat GroupCBRNE or HazMat Group• SHED or Cafeteria Division, etc.SHED or Cafeteria Division, etc.

Team MembersTeam Members

Triage and Treatment Unit LeadersTriage and Treatment Unit Leaders• Triage and Treatment Team MembersTriage and Treatment Team Members

Hospital Emergency Response Unit (HERU)Hospital Emergency Response Unit (HERU)• Team MembersTeam Members


HIMS – Operations Section HIMS – Operations Section OrganizationOrganization

SHED Division Cafeteria Division CBRNE Group

Operations Section


Medical Care Group/DivisionMedical Care Group/DivisionMembersMembers

Medical Care Group/Division could consist of:Medical Care Group/Division could consist of: Medical Group/Division Supervisor:Medical Group/Division Supervisor:

• Triage Unit LeaderTriage Unit Leader Triage personnelTriage personnel

• Treatment Unit LeaderTreatment Unit Leader Treatment Dispatcher ManagerTreatment Dispatcher Manager Treatment ManagersTreatment Managers

• Immediate, Delayed and MinorImmediate, Delayed and Minor Patient Transport Group SupervisorPatient Transport Group Supervisor

• Medical Communications CoordinatorMedical Communications Coordinator• Air/Ground Ambulance CoordinatorAir/Ground Ambulance Coordinator


Medical Care Group/DivisionMedical Care Group/DivisionMembers (Cont’d)Members (Cont’d)

Command from the top downCommand from the top down Staff from the bottom up:Staff from the bottom up:

Start with Team or Unit when possibleStart with Team or Unit when possible Staff up as span of control is exceededStaff up as span of control is exceeded

Maintain unity of commandMaintain unity of command Divisions are geographical:Divisions are geographical:

North/South; East/West; 1North/South; East/West; 1stst floor/2 floor/2ndnd floor floor


Medical Care Group/DivisionMedical Care Group/DivisionMembers (Cont’d)Members (Cont’d)

Groups are functional:Groups are functional: Security, medical careSecurity, medical care CBRNE or HazMatCBRNE or HazMat

Groups can have Units:Groups can have Units: TriageTriage TreatmentTreatment Hospital Emergency Response Unit (HERU)Hospital Emergency Response Unit (HERU)

Units may have TeamsUnits may have Teams DecontaminationDecontamination


Medical Care Group/Division Medical Care Group/Division Organization Organization

Medical SupplyCoordinator

Triage Personnel

Triage UnitLeader

Treatment DispatchManager

Immediate TreatmentManager

Delayed TreatmentManager

Minor TreatmentManager

Treatment UnitLeader

Medical Care Group/Division Supervisor

Morgue Manager


HazMat/CBRNE Unit MembersHazMat/CBRNE Unit Members

HazMat/CBRNE Unit LeaderHazMat/CBRNE Unit Leader Entry Team LeaderEntry Team Leader Hospital Site Access Control LeaderHospital Site Access Control Leader Safe Refuge Area ManagerSafe Refuge Area Manager Decontamination Team LeaderDecontamination Team Leader Technical SpecialistTechnical Specialist Assistant Hospital Safety Officer – HazMatAssistant Hospital Safety Officer – HazMat


HazMat/CBRNE Unit OrganizationHazMat/CBRNE Unit Organization

Entry

Hospital Access Control

Safe Refuge Area

Decontamination

Technical Specialists

HazMat/CBRNEUnit


Hospital Emergency Response Hospital Emergency Response Unit* (HERU)Unit* (HERU)

HERU LeaderHERU Leader Hospital Emergency Response Team (HERT) LeaderHospital Emergency Response Team (HERT) Leader

Initial Assessment & TriageInitial Assessment & Triage Immediate TreatmentImmediate Treatment Delayed TreatmentDelayed Treatment Minor TreatmentMinor Treatment

*Unit can be replaced by a Team*Unit can be replaced by a Team


HERU/HERT OrganizationHERU/HERT Organization

InitialAssessment/

Triage

ImmediateTreatment

Delayed Treatment

Minor Treatment

HERU/HERT Leader


Decon Team MembersDecon Team Members

Decontamination Team LeaderDecontamination Team Leader Initial ContactInitial Contact Decon Triage*Decon Triage* Decon Site Access ControlDecon Site Access Control Decon Set-up and SupportDecon Set-up and Support

*Patient/victim is continually triaged*Patient/victim is continually triaged


Decon Team OrganizationDecon Team Organization

Initial Contact Decon Triage Decon Site

Access Control

Decon Set Up/

Support

Decon Team Leader


Scenario ObjectivesScenario Objectives

Identify initial incident objectivesIdentify initial incident objectives Incident prioritiesIncident priorities

Life Safety (staff and patients)Life Safety (staff and patients) Incident StabilityIncident Stability Property preservationProperty preservation

Activate ICSActivate ICS Fill positions as appropriate for the eventFill positions as appropriate for the event Key points:Key points:

Span of control (3 – 7)Span of control (3 – 7) Unity of commandUnity of command


Scenario – Planned EventScenario – Planned Event

Noble Hospital is Noble Hospital is planning their annual planning their annual fundraiser:fundraiser: A two day Fish Fry Festival. A two day Fish Fry Festival. Saturday and Sunday, Saturday and Sunday,

Noon to 10 pmNoon to 10 pm

Menu:Menu:

Fried catfish, Cole Slaw, Fried catfish, Cole Slaw, Beans, Hush Puppies, Beans, Hush Puppies, CornbreadCornbreadIce Cream ConesIce Cream ConesBeerBeerSodaSoda

Entertainment:Entertainment:8 bands, 2 magician shows8 bands, 2 magician shows

Vendors:Vendors:20 Arts & Craft booths20 Arts & Craft boothsChildren’s Play areaChildren’s Play area


Section ConsiderationsSection Considerations

Initial Incident ObjectivesInitial Incident Objectives What are the main functions for:What are the main functions for:

(Operations, Logistics, Planning and Finance/Admin)?(Operations, Logistics, Planning and Finance/Admin)?

Should the functions be divided?Should the functions be divided? If so, how?If so, how?


Scenario – Unplanned EventScenario – Unplanned Event

A complete, community-wide power outage has occurred A complete, community-wide power outage has occurred approximately 20 minutes ago. United Electric Company has approximately 20 minutes ago. United Electric Company has just informed you that there is a 50 mile blackout, cause is just informed you that there is a 50 mile blackout, cause is unknown. Outage expected to last 5-7 days.unknown. Outage expected to last 5-7 days.

Emergency generators functioning with enough fuel for 1.5 Emergency generators functioning with enough fuel for 1.5 days at current emergency load. Emergency equipment is days at current emergency load. Emergency equipment is working only. working only.

The following departments are not on emergency power:The following departments are not on emergency power:Business officeBusiness office RegistrationRegistrationInfection ControlInfection Control AdministrationAdministrationPhysical TherapyPhysical Therapy All offices in hospitalAll offices in hospitalPneumatic tube systemPneumatic tube system


Scenario – Unplanned Event (Cont’d)Scenario – Unplanned Event (Cont’d)

Departments on emergency power for critical functions:Departments on emergency power for critical functions:

Emergency DeptEmergency Dept ICU/CCUICU/CCU Medical gasesMedical gases

LabLab XRayXRay NurseryNursery

SurgerySurgery RecoveryRecovery Nursing UnitsNursing Units

PharmacyPharmacy SwitchboardSwitchboard Summer weather - 90Summer weather - 90°/58°°/58° Population 250,000Population 250,000 Two hospitals, multiple clinics in areaTwo hospitals, multiple clinics in area

Noble Hospital – 250 beds/85% full; total hospital staff 1800Noble Hospital – 250 beds/85% full; total hospital staff 1800







Scenario -- Mass Casualty EventScenario -- Mass Casualty Event

There was a stadium collapse at the fairgrounds.There was a stadium collapse at the fairgrounds.Capacity of the stadium is 5000 people. Report fromCapacity of the stadium is 5000 people. Report fromEMS indicate over 300 people injured with many fleeingEMS indicate over 300 people injured with many fleeingthe scene in private vehicles. The county Mass Casualtythe scene in private vehicles. The county Mass CasualtyPlan has been activatedPlan has been activated. .

Summer weather - 90Summer weather - 90°/58°°/58° Population 250,000Population 250,000 Two hospitals, multiple clinics in areaTwo hospitals, multiple clinics in area Noble Hospital – 250 beds/85% full; total hospital staff 1800Noble Hospital – 250 beds/85% full; total hospital staff 1800 ED has 20 beds – currently has 16 patientsED has 20 beds – currently has 16 patients







Scenario – Haz Mat IncidentScenario – Haz Mat Incident

Continuation of stadium collapseContinuation of stadium collapse

There were 20 people that were contaminatedThere were 20 people that were contaminatedWith Organophosphate when the holding tank With Organophosphate when the holding tank was punctured from a piece of the stadiumwas punctured from a piece of the stadium

Some have left the scene en-route to the Some have left the scene en-route to the hospital. EMS will be transporting 6 after hospital. EMS will be transporting 6 after gross decontamination (clothing removed gross decontamination (clothing removed and field shower) and field shower)







Transfer of CommandTransfer of Command

Transfer command to an equal or more qualified Transfer command to an equal or more qualified person person

Transfer of command requires:Transfer of command requires: Briefing of incident face to faceBriefing of incident face to face Notification of staff that transfer has occurred AND Notification of staff that transfer has occurred AND

the name of the new personthe name of the new person


Transfer of Command (Cont’d)Transfer of Command (Cont’d)

Command transfers to a Command transfers to a more qualifiedmore qualified IC when IC when necessarynecessary

The new IC will The new IC will always always receive a transfer-of-receive a transfer-of-command briefingcommand briefing

Hospitals and healthcare facilities must identify Hospitals and healthcare facilities must identify and train deputy ICsand train deputy ICs


SummarySummary

ICS can be used for planned AND unplanned ICS can be used for planned AND unplanned events involving the hospitalevents involving the hospital

Make the response fit the event – only fill the Make the response fit the event – only fill the positions that are neededpositions that are needed

Maintain span of control (3 – 7 people)Maintain span of control (3 – 7 people) Use branches and divisions as neededUse branches and divisions as needed Expand and contract assignments as neededExpand and contract assignments as needed

Transfer of Command must be done consistently Transfer of Command must be done consistently and completely and completely


Summary (Cont’d)Summary (Cont’d)

Incident priorities:Incident priorities: Life safety of care providersLife safety of care providers Patient stability and treatmentPatient stability and treatment Property conservationProperty conservation Protect the environmentProtect the environment

Unit ThreeUnit Three

Topic 3-1: Chemical and Biological Topic 3-1: Chemical and Biological Agents in TerrorismAgents in Terrorism



Overview of potential biological agents used in Overview of potential biological agents used in terrorismterrorism

Overview of potential chemical agents used in Overview of potential chemical agents used in terrorismterrorism

Overview of common syndromesOverview of common syndromes Define clinical management procedures for Define clinical management procedures for

chemical/biological agentschemical/biological agents Define guidelines for response plansDefine guidelines for response plans


Routes of ExposureRoutes of Exposurefor Chemical and Biological Agentsfor Chemical and Biological Agents

InhalationInhalation Inhalation of droplets, aerosols or vaporsInhalation of droplets, aerosols or vapors

AbsorptionAbsorption Intact skin, cuts or abrasionsIntact skin, cuts or abrasions

Mucous membranesMucous membranes

InjectionInjection Intentional or unintentionalIntentional or unintentional

IngestionIngestion Specific agent ingestionSpecific agent ingestion

Contaminated food or waterContaminated food or water


Bioterrorism (CDC Definition)Bioterrorism (CDC Definition)

“ “Bioterrorism is the intentional or threatened use of Bioterrorism is the intentional or threatened use of viruses, bacteria, fungi, toxins from living organisms viruses, bacteria, fungi, toxins from living organisms or other chemicals to produce death or disease in or other chemicals to produce death or disease in humans, animals or plants.”humans, animals or plants.”


Potential Bioterrorism AgentsPotential Bioterrorism Agents

Bacterial AgentsBacterial Agents AnthraxAnthrax BrucellosisBrucellosis CholeraCholera Pneumonic plaguePneumonic plague TularemiaTularemia Q FeverQ Fever

VirusesViruses SmallpoxSmallpox Venezuelan Equine EncephalitisVenezuelan Equine Encephalitis Viral Hemorrhagic FeverViral Hemorrhagic Fever

Biological ToxinsBiological Toxins BotulinumBotulinum Staph Entero-BStaph Entero-B RicinRicin T-2 MycotoxinsT-2 Mycotoxins


Mandatory Reporting GuidelinesMandatory Reporting Guidelines

> Know your state and local guidelines> Know your state and local guidelines

> Include them in your plans> Include them in your plans

ANDAND

> Train your staff> Train your staff


CDC Category Definitions of CDC Category Definitions of Diseases/AgentsDiseases/Agents

Category ACategory A - Highest priority - Highest priority Can be easily disseminated or transmitted from person to Can be easily disseminated or transmitted from person to

personperson Results in high mortality rates and have the potential for Results in high mortality rates and have the potential for

major public health impactmajor public health impact Might cause public panic and social disruption Might cause public panic and social disruption Require special action for public health preparednessRequire special action for public health preparedness

Category A – AgentsCategory A – Agents AnthraxAnthrax ( (Bacillus anthracisBacillus anthracis); ); BotulismBotulism ( (Clostridium Clostridium

botulinumbotulinum toxin); toxin); PlaguePlague ( (Yersinia pestisYersinia pestis); ); SmallpoxSmallpox (variola major); (variola major); TularemiaTularemia ( (Francisella tularensisFrancisella tularensis); and ); and Viral hemorrhagic feversViral hemorrhagic fevers (filoviruses [e.g., Ebola, Marburg] (filoviruses [e.g., Ebola, Marburg] and arenaviruses [e.g., Lassa, Machupo])and arenaviruses [e.g., Lassa, Machupo])


CDC Category Definitions of CDC Category Definitions of Diseases/Agents (cont)Diseases/Agents (cont)

Category B Category B – Second highest priority– Second highest priority Moderately easy to disseminateModerately easy to disseminate Result in moderate morbidity rates and low mortality ratesResult in moderate morbidity rates and low mortality rates Require special enhancements of CDC’s diagnostic Require special enhancements of CDC’s diagnostic

capacity and enhanced disease surveillancecapacity and enhanced disease surveillance

Category B – AgentsCategory B – Agents BrucellosisBrucellosis ( (BrucellaBrucella species); Epsilon toxin of species); Epsilon toxin of Clostridium Clostridium

perfringens; perfringens; Food safety threatsFood safety threats (e.g., (e.g., SalmonellaSalmonella species, species, Escherichia coliEscherichia coli O157:H7, O157:H7, ShigellaShigella); Glanders ); Glanders ((Burkholderia malleiBurkholderia mallei); Melioidosis (); Melioidosis (Burkholderia Burkholderia pseudomalleipseudomallei); Psittacosis (); Psittacosis (Chlamydia psittaciChlamydia psittaci); ); Q feverQ fever ((Coxiella burnetiiCoxiella burnetii))



Category B – Agents (Cont)Category B – Agents (Cont) Ricin toxinRicin toxin from from Ricinus communisRicinus communis (castor beans); (castor beans);

Staphylococcal enterotoxin BStaphylococcal enterotoxin B»»Typhus fever (Typhus fever (Rickettsia Rickettsia prowazekiiprowazekii); Viral encephalitis (alphaviruses [e.g., ); Viral encephalitis (alphaviruses [e.g., Venezuelan equine encephalitis, eastern equine Venezuelan equine encephalitis, eastern equine encephalitis, western equine encephalitis]); and Water encephalitis, western equine encephalitis]); and Water safety threats (e.g., safety threats (e.g., Vibrio choleraeVibrio cholerae, , Cryptosporidium Cryptosporidium parvumparvum))



Category CCategory C – Third highest priority – Third highest priority Includes emerging pathogens that could be engineered for Includes emerging pathogens that could be engineered for

mass dissemination in the future because of mass dissemination in the future because of

> availability> availability

> ease of production and dissemination> ease of production and dissemination

> potential for high morbidity/mortality > potential for high morbidity/mortality

rates and major health impactrates and major health impact

Category C – AgentsCategory C – Agents Nipah virus and hantavirus Nipah virus and hantavirus


Most Common Syndromes in Most Common Syndromes in Biological EventsBiological Events

Flu-like illnessesFlu-like illnesses Acute respiratory symptoms with feverAcute respiratory symptoms with fever Gastrointestinal symptoms/syndromesGastrointestinal symptoms/syndromes Skin lesions (small pox)Skin lesions (small pox) Acute neuromuscular syndromesAcute neuromuscular syndromes

Compliments of CDC/NIP/Barbara Rice


Clues to Biological Potential EventsClues to Biological Potential Events

Increase in the number of patients with similar Increase in the number of patients with similar symptomssymptoms

Large number of deathsLarge number of deaths Cluster of an illness from single areaCluster of an illness from single area Infection that is not endemic to areaInfection that is not endemic to area Common infections in unusual seasonsCommon infections in unusual seasons Increase/large number of sick/dead animalsIncrease/large number of sick/dead animals Intelligence from law enforcementIntelligence from law enforcement Stated threatStated threat


Priorities for ResponsePriorities for Response(All Hazards)(All Hazards)

Life safetyLife safety Staff Staff VictimsVictims

Incident stabilityIncident stability Property preservationProperty preservation Protection of the environmentProtection of the environment


Response Considerations for Response Considerations for Biological EventBiological Event

Planning:Planning: Develop policies and procedures for:Develop policies and procedures for:

• recognition recognition

• notification notification

• isolation/quarantineisolation/quarantine

Pre-exposure:Pre-exposure: Active immunizationActive immunization ProphylaxisProphylaxis Intelligence informationIntelligence information


Response Considerations for Response Considerations for Biological Event (Cont’d)Biological Event (Cont’d)

Incubation Period:Incubation Period: DiagnosisDiagnosis Active/passive immunizationActive/passive immunization Antimicrobial treatmentAntimicrobial treatment Public Health needs (isolation/quarantine)Public Health needs (isolation/quarantine)

Active Disease Period:Active Disease Period: DiagnosisDiagnosis Treatment (guided by diagnosis & symptoms)Treatment (guided by diagnosis & symptoms) Public Health needs (isolation/quarantine)Public Health needs (isolation/quarantine)


Clinical Consideration for Clinical Consideration for Biological Event Biological Event

Basic supplies/address surge capacity:Basic supplies/address surge capacity: Beds/linensBeds/linens Waste managementWaste management Lab suppliesLab supplies Medical supplies:Medical supplies:

• IV solutions and suppliesIV solutions and supplies

• Antibiotics (if needed)Antibiotics (if needed)

• Other medicationsOther medications


Clinical Consideration for Clinical Consideration for Biological Event (Cont’d)Biological Event (Cont’d)

Additional needs:Additional needs: Extended staffing plan (clinical/non-clinical)Extended staffing plan (clinical/non-clinical) Medical staffing planMedical staffing plan Mass casualty planMass casualty plan Mass fatality planMass fatality plan Media management plan (Joint Information Center)Media management plan (Joint Information Center)

• Mechanism to provide updates/info to staffMechanism to provide updates/info to staff


Clinical Consideration for Clinical Consideration for Biological Event (Cont’d)Biological Event (Cont’d)

Additional needs:Additional needs: Infection Control Practitioner (from hospital)Infection Control Practitioner (from hospital) Public Health representativePublic Health representative Considering activating the hospital ICS/UCSConsidering activating the hospital ICS/UCS Family support areaFamily support area Pharmaceutical stockpilesPharmaceutical stockpiles


Key PointsKey Points

Some exposures Some exposures maymay require decontamination but require decontamination but most do notmost do not

Large events may overwhelm your systemLarge events may overwhelm your system Assure that the right people are notified and included Assure that the right people are notified and included

in the responsein the response Implement Incident Command SystemImplement Incident Command System


RemindersReminders

Determine alternate care sites in the Planning PhaseDetermine alternate care sites in the Planning Phase Work with community partners in the Planning PhaseWork with community partners in the Planning Phase


Potential Chemical AgentsPotential Chemical Agents

Nerve AgentsNerve Agents Blister Agents (vesicants)Blister Agents (vesicants) Pulmonary AgentsPulmonary Agents Blood Agents (cyanides)Blood Agents (cyanides)

Toxic Industrial ChemicalsToxic Industrial Chemicals

Riot Control AgentsRiot Control Agents

View from World Trade Center. Compliment of CDC.


Comparative Toxicity of AgentsComparative Toxicity of Agents

0

1000

2000

3000

4000

5000

6000

CL CG AC H GB VX

AGENT (L) (L)(L)(L)(L)(L)

Ct50(mg-min/m3)


Nerve AgentsNerve Agents

Actions:Actions: Interferes with the action of the nervous systemInterferes with the action of the nervous system Similar to organophosphatesSimilar to organophosphates

Types:Types: Sarin (GB)Sarin (GB) Tabun (GA)Tabun (GA) Soman (GD)Soman (GD) GFGF VXVX

Tokyo, Japan Response to Sarin Attack.


Blister AgentsBlister Agents

Actions:Actions: Cause cellular damage leading to cellular death (skin, Cause cellular damage leading to cellular death (skin,

mucous membranes, eyes, systemic effects)mucous membranes, eyes, systemic effects) Effects begin immediately, but blisters may be delayed Effects begin immediately, but blisters may be delayed

(mustard) (mustard) Types:Types:

Mustard aka “mustard gas” (H)Mustard aka “mustard gas” (H) Sulfur mustard (HD)Sulfur mustard (HD) Lewisite (L)Lewisite (L) Mustard and Lewisite (HL)Mustard and Lewisite (HL) Phosgene Oxime (CX):Phosgene Oxime (CX):

• Pulmonary agent with vesicant effectsPulmonary agent with vesicant effects

Iran Victim of Mustard Agent Attack, CDC


Pulmonary AgentsPulmonary Agents

Actions:Actions: Damages the lining in the lung and cause fluid leakageDamages the lining in the lung and cause fluid leakage Delayed pulmonary edemaDelayed pulmonary edema

Types:Types: Phosgene (CG)Phosgene (CG) Chlorine (CL)Chlorine (CL) RicinRicin

Pulmonary edema. Compliments of CDC.


Blood Agents: CyanidesBlood Agents: Cyanides

Actions:Actions: Blocks the use of oxygen in the cells of the bodyBlocks the use of oxygen in the cells of the body

• Causing asphyxiation in each cellCausing asphyxiation in each cell Least toxic of the “lethal” chemical agentsLeast toxic of the “lethal” chemical agents

Types:Types: AC and CKAC and CK

Toxic industrial chemicals (TIC):Toxic industrial chemicals (TIC): Chlorine, ammonia, arsenicChlorine, ammonia, arsenic Hydrocarbon (benzene)Hydrocarbon (benzene) Highly toxic, corrosive and irritating chemicalsHighly toxic, corrosive and irritating chemicals

Likely terrorist’s targets of opportunityLikely terrorist’s targets of opportunity


Riot AgentsRiot Agents

Actions:Actions: Causes irritation to eyes, mouth, throat, lungs and Causes irritation to eyes, mouth, throat, lungs and

skinskin Immediate symptoms are intense and cause people Immediate symptoms are intense and cause people

to try and stop the effectsto try and stop the effects Types:Types:

MaceMace Pepper SprayPepper Spray


Clues To Potential Clues To Potential Chemical ExposureChemical Exposure

Shortness of breath/respiratory difficultyShortness of breath/respiratory difficulty Itchy/burning/watery eyesItchy/burning/watery eyes Runny noseRunny nose Skin irritationSkin irritation SLUDGESLUDGE Patients reporting odor just prior to symptomsPatients reporting odor just prior to symptoms


Clues To Potential Clues To Potential Chemical Exposure (Cont)Chemical Exposure (Cont)

Increase number of patients with same symptomsIncrease number of patients with same symptoms Sick/dead animals and birdsSick/dead animals and birds Sick/affected first respondersSick/affected first responders Intelligence from lawIntelligence from law enforcementenforcement Stated threatStated threat


Planning Considerations for Planning Considerations for Chemical AgentsChemical Agents

Planning PhasePlanning Phase Hazard assessmentHazard assessment Designate Triage and Decon areasDesignate Triage and Decon areas Develop Respiratory Protection ProgramDevelop Respiratory Protection Program Develop Decontamination ProgramDevelop Decontamination Program Implement Incident Command SystemImplement Incident Command System Purchase equipmentPurchase equipment Develop policies and proceduresDevelop policies and procedures Train staffTrain staff Practice and exercisePractice and exercise


Response Plan Considerations Response Plan Considerations for Chemical Agentsfor Chemical Agents

RecognitionRecognition Prevent secondary contaminationPrevent secondary contamination

Escort patient immediately outside/to decon areaEscort patient immediately outside/to decon area Initiate hospital HazMat response:Initiate hospital HazMat response:

Notify appropriate staffNotify appropriate staff Don appropriate CPC&EDon appropriate CPC&E


Response Plan Considerations for Response Plan Considerations for Chemical Agents (Cont)Chemical Agents (Cont)

Determine need for decontaminationDetermine need for decontamination Decontaminate patientsDecontaminate patients

Provide appropriate medical careProvide appropriate medical care Decontaminate staffDecontaminate staff Secure areaSecure area Decontaminate equipment, as appropriateDecontaminate equipment, as appropriate


Antidotes Are Available forAntidotes Are Available forSome Chemical AgentsSome Chemical Agents

Nerve agents/organophosphatesNerve agents/organophosphates Atropine – blocks the effects of the chemical that Atropine – blocks the effects of the chemical that

causes over stimulationcauses over stimulation 2PAMCl – neutralizes the nerve agent actions2PAMCl – neutralizes the nerve agent actions CANA – Convulsive Antidote, Nerve AgentCANA – Convulsive Antidote, Nerve Agent

• Diazepam, when requiredDiazepam, when required CyanideCyanide

Cyanide Kit containsCyanide Kit contains• Amyl nitrate (inhalant)Amyl nitrate (inhalant)• Sodium nitrite (injectable)Sodium nitrite (injectable)• Sodium thiosulfate (injectable)Sodium thiosulfate (injectable)


Hospital Partners for Biological & Hospital Partners for Biological & Chemical Response PlansChemical Response Plans

HazMat Team Patient

Administration

Infection Control

Laboratory

Housekeeping

ED Staff

Clinical Services

Risk & Materials Management

Legal

Hospital Emergency Management

PIO

Plant Operations


Community Partners for Biological & Community Partners for Biological & Chemical Response PlansChemical Response Plans

Hospital

State Health Dept

Law Enforcement

State LabLocal Haz Mat Team

LEPC Local Health Dept

Elected Officials

CDC EMS

FBI

MediaCoroner

County Emergency Management


Key PointsKey Points

Some exposures Some exposures maymay require decontamination but require decontamination but you must determine if patient was actually you must determine if patient was actually contaminatedcontaminated

Large events may overwhelm your system quickly Large events may overwhelm your system quickly and without noticeand without notice

Notified and included the right people in the responseNotified and included the right people in the response


SummarySummary

Routes of exposure for chemical and biological Routes of exposure for chemical and biological agentsagents

Overview of some potential biological and chemical Overview of some potential biological and chemical agents used in terrorismagents used in terrorism

Overview of common syndromesOverview of common syndromes Guidelines for response plansGuidelines for response plans

Documents

Hospital Emergency Response Training (HERT) for Mass Casualty Incidents (MCI) Train-the-Trainer Course Course Code: B461