CHAPTER

50

Terrorism

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

i Risks and responsibilities of operating on the scene of a natural or man-made disaster. (pp 2289–2311)

i

Knowledge Objectives

1. List key questions to consider when responding to a terrorist event. (pp 2289–2290)

2. Define international and domestic terrorism. (pp 2290–2291)

3. Define and specify types of terrorist groups. (pp 2291–2293)

4. List various examples of terrorist agendas. (pp 2291–2293)

5. Discuss the color-coded advisory system’s replacement with the National Terrorism Advisory System (NTAS). (pp 2293–2294)

6. Discuss what actions paramedics should take during the course of their work to heighten their ability to respond to and survive a terrorist attack. (pp 2293–2297)

7. List various examples of potential terrorist targets. (pp 2293–2294)

8. Discuss factors to consider when responding to a potential weapon of mass destruction incident, including pre-incident indicators, the type of location, the type of call, the number of patients, and victims’ statements. (pp 2293–2297)

9. Discuss key response actions to take at the scene of a terrorist event, including establishing scene safety, ensuring personal protection, notification procedures, requests for resources, and establishing or working within command. (pp 2294–2297)

10. Define secondary device, and discuss the importance of continually reassessing scene safety. (p 2297)

11. List the four main categories of weapons of mass destruction. (p 2297)

12. Discuss specific types of devices used by terrorists, including explosives, ammonium nitrate, and suicide bombers. (pp 2297–2298)

13. Define terms related to chemical agents, including persistency, volatility, contact hazard, and vapor hazard. (p 2298)

14. Describe specific vesicant agents. (pp 2298–2299)

15. Discuss signs, symptoms, and treatment for vesicant exposure. (pp 2298–2299)

16. Describe specific pulmonary agents. (pp 2299–2300)

17. Discuss signs, symptoms, and treatment for exposure to a pulmonary agent. (pp 2299–2300)

18. Describe specific nerve agents. (pp 2300–2302)

19. Discuss signs, symptoms, and treatment for exposure to a nerve agent. (pp 2300–2302)

20. Describe specific industrial chemicals and insecticides. (pp 2302–2303)

21. Discuss signs, symptoms, and treatment for exposure to a cyanide agent. (pp 2302–2303)

22. Define terms related to biologic agents, including dissemination, disease vector, communicability, and incubation. (p 2303)

23. Describe signs, symptoms, and treatment for smallpox. (pp 2304–2305)

24. Describe signs, symptoms, and treatment for viral hemorrhagic fevers. (pp 2304–2306)

25. Describe signs, symptoms, and treatment for inhalation and cutaneous anthrax. (p 2306)

26. Describe signs, symptoms, and treatment for plague. (pp 2306–2307)

27. Describe signs, symptoms, and treatment for exposure to botulinum toxin. (p 2307)

28. Describe signs, symptoms, and treatment for exposure to ricin. (pp 2307–2308)

29. Define syndromic surveillance, and discuss its importance during a potential terrorist event. (p 2308)

30. Define radiation, and describe the difference between alpha, beta, gamma, and neutron radiation. (pp 2309–2310)

31. Describe what a radiologic dispersal device, or dirty bomb, is and how it is used for terrorism. (p 2310)

32. List protective measures to take when responding to a radiologic event. (p 2311)

33. Discuss medical management of a patient who was potentially exposed to radiation. (p 2311)

Skills Objectives

1. Demonstrate how to use a nerve agent antidote kit. (p 2302)

i Introduction

Over the last decade, the threat posed by international and domestic acts of terrorism has sharply increased. Several times a week a terror attack occurs someplace in the world. Preparing for response to an act of terror has become a reality for EMS workers in the United States and around the world. It is possible that you may respond to a terrorist event during the span of your career. International terrorists as well as domestic groups have increased their targeting of civilian populations with acts of terror. The question is not will terrorists strike again, but rather when and where they will strike. You must be mentally and physically prepared for the possibility of a terrorist event.

Your health and safety is a primary concern when you are called to respond to terrorist attacks. The threat that terrorism poses to the health and safety of paramedics was realized even before the September 11, 2001, attacks. The sarin attacks in Tokyo in 1996 sickened 135 of the 1,336 (approximately 10%) paramedics who rushed to the scene, because they lacked proper personal protective equipment (PPE). The attacks on September 11, 2001, brought emergency responder health and safety to the forefront because 450 emergency responders were killed on that day, representing over 15% of the total victims.

Many more paramedics and EMTs were injured, developed chronic disorders, or experienced depression and physiologic problems as a result of their response.

The chapter, Disaster Response discusses concerns related to disasters in general, but there are some issues specific to terrorist attacks that must be considered. Although it is difficult to anticipate and plan a response to many terrorist events, there are several key principles that apply to every response. This chapter describes how you can prepare to respond to these events by discussing types of terrorist events and patient management. You will also learn the signs, symptoms, and treatment of patients who have been exposed to chemical, biologic, radiologic, nuclear, and explosive (CBRNE) agents or injured by a suicide bomb and explosive attacks. Lastly, issues of responder health and safety at the scene of a terrorist attack will be discussed in detail. At the end of this chapter, you will be able to answer the following key questions:

i What are the most frequent sites for a terrorist attack?

i What are your initial actions when faced with a terrorist event?

i Who should you notify, and what should you tell them?

i What types of additional resources might you require?

i How do you ensure your own safety, your partner’s safety, and the safety of victims?

i How should you proceed to address the needs of the victims?

i What is the clinical presentation of a patient exposed to a weapon of mass destruction (WMD)?

i How are WMD patients to be assessed and treated?

i How do you avoid becoming contaminated or cross-contaminated with a WMD agent?

i How do you ensure your health after your response to the incident has concluded?

YOU are the Medic   PART 1

You and your partner are dispatched to an unknown medical incident at the courthouse. The dispatcher informs you that the communications center is receiving multiple calls for persons having difficulty breathing within the courthouse where a high-profile murder trial was underway. Prior to arrival, you are asked to stage three blocks north of the courthouse until the scene is declared safe. The HazMat team is en route with an estimated time of arrival of 2 minutes. Incident command is being set up in a parking lot across the street from the courthouse.

Your unit is assigned to the treatment area. There are approximately 25 people outside of the courthouse with respiratory symptoms with an unknown number of patients inside. Initial reports indicate there was a strange odor throughout the second floor where the trial was being held. Decontamination areas are being established. Approximately 35 minutes into the call you receive your first patient.

Recording Time: 1 Minute

Appearance

Man in his mid-20s, in respiratory distress. Patient appears confused.

Level of consciousness

Verbal (knows his name, but does not know where he is or how he got there)

Airway

Open

Breathing

Increased work of breathing with accessory muscle use and audible expiratory wheezes

Circulation

Strong radial pulse, decreased

1. What are some clues that might help you treat your patient?

2. Biologic agents can be modified in a laboratory to increase their impact on target populations. What are the primary types of biologic agents that you may encounter during a terrorist attack?

EMS providers are encouraged to seek additional training and participate in drills and exercises to hone the skills needed to respond safely to a terrorist event.

i Terrorism

The US Department of Justice defines terrorism as a violent act dangerous to human life, in violation of the criminal laws of the United States or any state or subdivision thereof, to intimidate or coerce a government, the civilian population, or any segment thereof, in furtherance of political or social objectives. Mass destruction, assassinations, and kidnappings that are conducted with the aim to influence or affect a government are also defined as terrorism. Terrorists pose a threat to nations and cultures everywhere. Terrorism is commonly used as a form of asymmetric warfare, in which groups wage war against a population with unconventional weapons and covert tactics that are unequal—for example—when there are differences in military resources or capabilities, and are thus asymmetrical.

Terrorism is common around the world, with frequent attacks occurring across the Middle East, where terrorist groups frequently strike civilian populations in crowded outdoor markets, at sporting and religious events, and at weddings. In Colombia and oil-rich regions in Africa, political terrorist groups target oil resources (refineries, pipelines, and infrastructure) as a means to instill fear in multinational corporations and governments. Often, vulnerable innocent people are the victims of acts of political and economic terror. Terrorists often lack a sense of discrimination when selecting their targets, and have been known to intentionally attack children at schools and camps. In one such attack in 2004, over 30 heavily armed male and female terrorists and suicide bombers overran a school in Beslan, Russia, and held children as hostages over the course of 3 days. When the siege was over, 334 hostages were killed, many of them children, who were too weak after 3 days of starvation to escape the massacre Figure 1. In another attack in 2011 in Norway, a lone terrorist exploded a car bomb in Oslo and then targeted a summer camp, opening fire and killing 69 people.

i International Terrorism

The US Federal Bureau of Investigation defines two types of terrorism: international terrorism and domestic terrorism. International terrorism, also known as cross-border terrorism, is defined as acts of terror committed by foreign agents. International terrorism can be further categorized into the following subgroups:

i Non-state-supported terrorism. Terrorism that is either indigenous or transnational, and that does not receive direction or support from a government.

i State-sponsored terrorism. Terrorism that is funded or supported by a government; the government holds close ties with the terrorist group, but the terrorist group still acts independently.

i State-directed terrorism. Terrorism directed by a government; terrorists act as direct agents of the government.

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Figure 1 In 2004, a terrorist attack at a school in Beslan, Russia resulted in hundreds of deaths.

The emergence of international terrorism has changed the lives of every American citizen and hundreds of millions more people around the globe. It has implications for paramedics who will respond to these events. Events such as the attack on New York’s World Trade Center in 1993 and September 11, 2001 (9/11), have changed the way Americans live and travel Figure 2 and Figure 3. In Mumbai, India international terrorists stormed two landmark hotels popular with Western tourists, in a coordinated attack that occurred at 11 sites (including a women and children’s hospital and a train station) over the course of 3 days in November of 2008. These highly organized terror attacks killed over 160 people and injured more than 300.

i Domestic Terrorism

Whereas terrorist attacks planned by foreigners have dominated the discussion and planning for emergency response, domestic terrorism is also a fact of life. Domestic terrorism is defined as when the perpetrators are citizens of the country that is being attacked. In the United States, domestic terrorists have planned attacks multiple times within the last several years post-9/11.

The Centennial Olympic Park bombing in Atlanta during the 1996 Summer Olympics injured over 100 people and killed 2 Figure 4. The destruction of the Alfred P. Murrah Federal Building in Oklahoma City in 1995 took the lives of 168 people, including 19 children Figure 5. These are early examples of domestic terrorist attacks. Post-9/11, there have been several domestic terrorist attacks in the United Kingdom, and a number of small-scale successful, failed, or thwarted plots in the US. Examples include the following events:

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Figure 2 The terrorist attack on the World Trade Center in 1993.

i The thwarted 2006 Sears Tower plot

i The thwarted 2006 Toledo, Ohio, terror plot

i 2007 Fort Dix, New Jersey, attack plot

i 2008 bombing of Armed Forces recruiting office in Times Square

i 2009 Fort Hood, Texas, shooting that killed 13 people and wounded 30 others

i 2009 Little Rock, Arkansas, Armed Forces recruiting office shooting that killed one recruiter and injured a second recruiter

i The thwarted 2009 New York subway and United Kingdom plots

i The failed 2010 Times Square car bombing

i 2010 Austin, Texas IRS office attack that killed one worker and the suicide attacker who flew his plane into the building

i The failed 2010 Portland, Oregon, car bomb plot

i 2011 mail bombings of two Maryland government buildings

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Figure 3 The September 11 attack on the World Trade Center accounted for the majority of the deaths caused by terrorists in 2001. A. The World Trade Center attack. B. The Pentagon attack.

These are just a few examples of domestic terror attacks and plots involving US citizens or legal residents.

i Types of Terrorist Organizations

Terrorist organizations generally can be categorized as one or more of the following:

1. Violent religious groups/doomsday cults. These groups are especially dangerous because they often seek apocalyptic violence or mass murder as a means to their ends.

They see other religions or “nonbelievers” as worthy targets for death, and part of their apocalyptic doctrine is to eradicate or cleanse a region (or the entire earth) of those who do not practice their faith. This includes intra-religious terrorism, between two different sects of the same religion (such as Shiite vs. Sunni Muslims). These groups include terrorist organizations such as Aum Shinrikyo, who carried out sarin chemical attacks in Tokyo between 1994 and 1995.

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Figure 4 Domestic terrorists bombed the Centennial Olympic Park in Atlanta during the 1996 Summer Olympics.

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Figure 5 Domestic terrorists bombed the Alfred P. Murrah Federal Building in Oklahoma City in 1995.

2. Extremist political/social groups. These include violent separatist groups and those who seek political, economic, or social freedom. They may also seek to kill or evict foreigners, migrants, or those with different ethnic, racial, sociologic (poor or lower class), and/or cultural backgrounds from their region. They often use terror to influence economic or immigration politics and the drawing or redrawing of geopolitical borders to claim or reclaim land.

3. Technology or “cyber” terrorists. These groups attack a technologic infrastructure (power grid, Internet, intranet, telecommunications) using technology as a means to draw attention to their cause. Common methods used by these terrorists include “hacking” (gaining illegal access) into computer systems, and introducing corruptive computer programs such as viruses, worms, and “Trojan horses.” These terrorists seek to extract valuable information stored in the computer systems, but may also seek to do harm to not just the computers but also the machines or processes that they control (security systems, mechanized work, electrical power). These attacks can be extremely difficult to detect early (if at all), and to shut down. Due to the level of sophistication of these types of attacks, these terrorists generally work in groups, take advantage of unsecured networks, and can even use an unsuspecting person’s computer to launch an attack.

4. Single-issue terrorist groups. These include anti-abortion groups, animal rights groups, anarchists, racists, or even eco-terrorists who threaten or use violence as a means to advance their views or goals. These groups often represent the violent fringe or a splinter group of a legitimate non-violent group or movement that seeks to effect change through legal and socially acceptable means. However, if such non-violent methods are seen as ineffective, or time-consuming, or if there is a disagreement in methodology or philosophy between factions in the group, a smaller group may break off and look toward violence for a more immediate and effective response to their demands.

5. Narcoterrorists. Narcoterrorism is the use of terror to take control of a region, its politics, or government with the goal of manufacturing, distributing, and selling (trafficking) drugs without prosecution. They often target military, police, and anti-drug politicians or government officials (and their families), as well as innocent civilians in an effort to gain control over an entire region, usurping the power of the local authority. As a result of the revenue of the drugs that they manufacture and/or distribute, these groups are generally more heavily armed, organized, and funded than the local authorities. As such, they exert disproportionate and massive amounts of regional control. Other terrorist groups, such as extremist political or violent religious organizations, often use the drug trade to fund their terrorist activities. However, strictly speaking this would not classify as narcoterrorism, because they are not using terror for the furtherance of drug distribution.

Additional subcategories of terrorist groups include the following:

i Hate groups. Examples include the Ku Klux Klan, Skinheads, Neo-Nazis, Black Separatist, Neo-Confederates, and others targeting single issues such as homosexuality or affirmative action.

i Patriot groups. These frequently overlap with some of the hate groups.

i Militia groups. Minutemen, usually against central government, sometimes calling for secession of their states from the union.

i Common-law groups. Freeman; groups that distrust all government.

i Cult groups. Varied, many times religious-based doctrine.

i Single-issue groups. Fringe members of a group that is not a terrorist group, and who may commit terrorist acts, for example against animal laboratories.

i Lone wolves. Examples include people such as Ted Kaczynski (Unabomber) and Eric Rudolph (Olympic Park Bomber). These persons are extremely hard to detect and deter due to the lack of ties to an “umbrella” organization.

Terrorist groups may exhibit traits of several of these groups or even join forces with other groups that use different methods but strive for the same goals or wish to attack the same target. For example, a narcoterrorist group may join forces with technology terrorists or independently initiate a cyber attack on law enforcement’s computer systems to eliminate records or gain information.

Al Qaeda is the most infamous international terrorist organization. Their influence and membership has spread across the Middle East over the last two decades, leading to multiple Al Qaeda offshoots or affiliated branches. The hallmark of these groups is violent, simultaneous, coordinated attacks. This is primarily meant to confuse, spread thin, and overwhelm emergency response to the incidents, but also to boast the level of sophistication and planning that they have put into committing the acts. These groups exhibit trends toward apocalyptic violence to affect a combination of political, geopolitical, and religious goals.

Terrorist organizations thrive in regions with weak or corrupt regional governments. This is an ideal environment for them to train terrorist recruits, store equipment, and plan and operate effectively. As such, many of these groups look to establish training camps and bases of operation in remote, austere locations where they can function with impunity, as well as protect themselves using guerilla warfare tactics.

Most terrorist attacks require precise coordination between multiple terrorists or “actors” working together. Recruiters identify willing actors and bring them into the organization, where they are trained, financed, and provided equipment and intelligence on their target(s), as well as transportation and often lodging. Twenty terrorists worked together to commit the worst act of terror in United States history on September 11, 2001, but there were dozens more people directly and indirectly involved in planning and helping to execute the attacks. Four terrorists worked together to carry out the London subway bombings on July 7, 2005, but many more were involved in their training, financing, and planning. However, in a few instances there has been a single “actor” terrorist who has struck with devastating results. Examples of terrorists who acted alone include those who carried out the Atlanta abortion clinic attacks, the 1996 Summer Olympics attack, and the Oklahoma City bombing.

i Paramedic Response to Terrorism

i Recognizing a Terrorist Event (Indicators)

Most acts of terror are covert, which means that the public safety community generally has no prior knowledge of the time, location, or nature of the attack. This element of surprise makes responding to an event more complex. You must constantly be aware of your surroundings and understand the possible risks for terrorism associated with certain locations, at certain times. It is therefore important that you know what locations or events in your jurisdiction would be considered high-value targets for terrorists. Examples of potential high-value targets for terrorists include the following:

i Military bases/installations and military recruiting centers

i Rail and metro transport systems

i Large bus depots

i Airports/seaports

i Chemical plants/chemical transfer stations or chemical transportation (pipelines, rail)

i Petrochemical (gasoline, natural gas, liquid natural gas) storage or transportation

i Dams and reservoirs

i Bio labs

i All large gathering spaces/places (stadiums, sporting arenas, parade routes)

i Government buildings (court houses, federal buildings, public safety headquarters)

i Hospitals (as secondary attack locations)

i Large religious venues (church, mosque, temple, synagogue)

i Large shopping centers and malls

i Large demonstrations or rallies

i Large financial centers (financial markets or exchanges)

i National symbols (monuments or memorials)

It is important to understand the National Terrorism Advisory System (NTAS), which replaced the color-coded Homeland Security Advisory System that had been instituted in 2002 by the federal government through the Department of Homeland Security (DHS). NTAS alerts apply to threats to the United States and its territories. The NTAS alerts responders to the potential for an attack, and, as far as practicable, will give specifics of the current threat. If the information is available, the NTAS alert will provide specific details related to who will be potentially affected, such as the geographic area, transportation concerns, and the nature of the threat. It will also include steps that people or communities can take to protect themselves in response to the threat. The advisory will specify whether the threat is elevated (there is no specific information about the timing or location), or imminent (the threat is believed to be impending or expected to occur soon). The alert will be publically announced via posting at DHS.gov/alerts and releasing the alert to the news media. DHS will also distribute alerts via social media such as Facebook and Twitter. Updated NTAS alerts are issued if information related to the threat changes; updated alerts are distributed in the same manner as initial alerts. Alerts are automatically canceled on a designated expiration date.

The DHS has not issued specific recommendations for EMS personnel to follow in response to the alert system. Follow your local protocols, policies, and procedures. It is your responsibility to make sure you know the threat level at the start of your workday. Many EMS organizations are starting to display the NTAS system on boards where they can be seen by staff when they arrive for a shift. On the basis of the current information available, take appropriate actions and precautions while continuing to perform daily duties and responding to calls.

Understanding and being aware of the current threat is only the beginning of responding safely to calls. Once you are on duty, you must be able to make appropriate decisions regarding the potential for a terrorist event. In determining the potential for a terrorist attack, on every call you should observe the following:

i Pre-incident indicators. Has the NTAS posted a threat warning? Has there been a recent increase in violent political activism? Are you aware of any credible threats made against the location, gathering, or occasion?

i Type of location. Is the location a monument, infrastructure, government building, or a specific type of location such as a temple? Is there a large gathering such as a parade or political demonstration? Is there a special event taking place such as a college football game?

i Type of call. Is there a report of an explosion or suspicious device nearby? Does the call come into dispatch as someone having unexplained coughing and difficulty breathing? Are there reports of people fleeing the scene?

i Number of patients. Are there multiple patients with similar signs and symptoms? This is probably the single most important clue that a terrorist attack or an incident involving a WMD has occurred.

i Victims’ statements. This is probably the second best indication of a terrorist or WMD event. Are the patients fleeing the scene giving statements such as, “Everyone is passing out,” “There was a loud explosion,” or “There are a lot of people shaking on the ground.” If so, something is occurring that you do not want to rush into, even if it is determined not to be a terrorist event.

Words of Wisdom

One of the easiest ways for you to distinguish between a nonterrorist multiple-casualty event and a terrorist event is that the intentional use of a WMD affects multiple persons. These casualties will generally exhibit the same signs and symptoms. It is highly unlikely for more than one person to experience a seizure at any given time. It is not uncommon to find multiple patients complaining of difficulty breathing at the scene of a fire. However, the same report in the subway at rush hour, when no smell of smoke has been reported, is certainly cause for suspicion. In these situations, you must use good judgment and resist the urge to “rush in and help,” especially when there are multiple victims from an unknown cause.

i Response Actions

Once you suspect that a terrorist event has occurred or a WMD has been used, there are certain actions to take to ensure that you will be safe and be in the proper position to help the community:

i Ensure scene safety and personal safety

i Notify your dispatch and/or supervisor of the incident

i Request additional/specialized resources

i Establish command

i Initiate multiple-casualty incident procedures

Scene Safety

Ensure that the scene is safe. If you have any doubt that it may not be safe, do not enter. When you are dealing with a WMD scene, it is safe to assume that you will not be able to enter where the event has occurred—nor do you want to. The best location for staging is upwind and uphill from the incident. Wait for assistance from those who are trained in assessing and managing WMD scenes. Also remember the following:

i Failure to park your vehicle at a safe location can place you and your partner in danger Figure 6.

i If your vehicle is blocked in by other emergency vehicles or damaged by a secondary device (or event), you will be unable to provide patients with transportation, or escape yourself Figure 7.

Responder Safety (Personal Protection)

Emergency response by its nature is a dangerous profession; it is associated with exposure to a multitude of occupational hazards from ergonomics (lifting and carrying), to workplace violence, hazardous materials (HazMat), and vehicle crashes, to name just a few. Each day paramedics operate on the scene of hazardous and potentially life-threatening scenes, often without significant injuries or loss of life. However, when emergency workers respond to the scene of a major terrorist incident, research shows that responder health and safety suffer greatly. The uniqueness and uncertainty of terrorist and WMD incidents can cloud the decision-making process, and paramedics can develop tunnel vision—a situation in which a person does not see the overall picture, but focuses on only one aspect of it.

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Figure 6 Park your vehicle at a safe location and distance.

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Figure 7 Make sure that your vehicle is not blocked in by other emergency vehicles.

At large-scale events, you will arrive well before environmental health personnel or trained health and safety professionals arrive. For this reason, you need the following key resources when responding to potentially hazardous scenes:

i Awareness of measures to take for self-preservation

i A culture of safety within your organization

i Previous knowledge, fit-testing, experience, and comfort using multiple types and brands of PPE

i The proper PPE

i Self-enforcement of all protective measures

The best form of protection from a WMD agent is preventing yourself from coming into contact with the agent. The greatest threats facing you in a WMD attack are contamination and cross-contamination. Contamination with an agent occurs when you have direct contact with the WMD or are exposed to it. Cross-contamination occurs when you come into contact with a contaminated person who has not yet been decontaminated. Decontamination of patients is an important part of medical management of patients who have been exposed to or contaminated with a chemical, biologic, radiologic, or nuclear agent, or an explosive. Decontamination is covered in the chapter, Hazardous Materials. If EMS personnel have been appropriately trained in decontamination and have the appropriate PPE, they may be involved in decontamination per their protocols.

YOU are the Medic   PART 2

Your partner quickly applies a nonrebreathing mask at 15 L/min while you begin your assessment. The patient is reporting chest pain and shortness of breath. You observe intercostal and supraclavicular retractions. Lung sounds are diminished but clear. The patient denies any past medical history or allergies to medications and is repeatedly asking you what happened.

Recording Time: 5 Minutes

Respirations

28 breaths/min, shallow

Pulse

Radial pulse, 124 beats/min, regular and strong

Skin

Pink, warm, and dry

Blood pressure

172/86 mm Hg

Oxygen saturation (SpO2)

96% on 15 L/min nonrebreathing mask

Pupils

Dilated, equal, and reactive to light

3. On the basis of the information you have, what do you think your patient was exposed to?

4. What should your initial treatment consist of?

Notification Procedure/Resource Requests

When you suspect a terrorist or WMD event has taken place, notify the dispatcher, provided that communication is functioning properly. Vital information needs to be communicated effectively if you are to receive the appropriate assistance. Inform dispatch of the nature of the event, any additional resources that may be required, the estimated number of patients, and the upwind route of approach or optimal route of approach.

Words of Wisdom

IMPORTANT NOTE: In situations where there may be explosive agents present, paramedics are advised to restrict all radio and cell phone communications because they may trigger unexploded ordnance (weapons or other munitions or military equipment that may explode). Refer to your local or regional operations guidelines for response to suspicious packages or bomb threat procedures.

It is extremely important to establish a safe staging area where other units will converge. Be mindful of access and exit routes when you direct units to respond to a location. It is unwise to have units respond to the front entrance of a hotel or apartment building that has had an explosion, because perpetrators may plant secondary devices at entrances, expecting responders to enter there. Finally, trained responders in the proper protective equipment are the only persons equipped to handle the WMD incident. These specialized units, traditionally HazMat teams, must be requested as early as possible due to the time required to assemble and dispatch the team and their equipment. Many jurisdictions share HazMat teams, and the team may have to travel a long distance to reach the location of the event. It is always better to be safe than sorry; call the team early and the outcome of the call will be more favorable. Keep in mind that there may be more than one type of device or agent present.

Command

If the Incident Command System (ICS) is already in place, then you should immediately seek out the medical staging supervisor to receive your assignment.

The first arriving provider on the scene must begin to sort out the chaos and define his or her responsibilities under the ICS. As the first person on scene, the paramedic may need to establish “EMS or Medical Command” until additional personnel arrive. Depending on the circumstances, you and other paramedics may function as medical branch supervisors, triage supervisors, treatment supervisors, transportation or logistic supervisors, or staff. Generally, the most senior paramedic on the scene acts as the medical branch director until relieved by a supervisor or EMS physician. Initial tasks that the first arriving paramedic must perform are as follows:

i Report to incident command post (in unified command).

i Establish a medical branch under the operations section.

i Determine the scope and scale of the incident:

– Type of incident

– Hazards to responders and victims

– Number of patients/deceased

– Safe access, egress, and staging locations

– Gather information on decontamination area(s), and hot, warm, and cold zones.

i Regularly gather and disseminate information to dispatch.

i Establish and assign a supervisor for the following areas:

– Decontamination (if established)

– Triage

– Treatment

img Minor/“walking wounded” (green tag)

img Delayed (yellow tag)

img Urgent (orange tag, used in some areas)

img Immediate (red tag)

img Deceased (black tag)

– Transportation (departing units)

– Staging (arriving personnel and units)

– Rehabilitation (assessment and treatment for first responders only)

i Report all EMS activities to the operations section chief.

If the ICS is already in place, then you should immediately seek out the EMS staging supervisor to receive your assignment. The ICS and its components are discussed in further detail in the chapter, Incident Management and Multiple-Casualty Incidents.

Words of Wisdom

Secondary devices may include various types of electronic equipment such as cell phones or pagers that are detonated when “answered.” They may also be set to a timer for when responders are anticipated to arrive. For these reasons, it is important that any uninjured person be directed from the scene to the triage area.

Paramedics should expect a heavy police presence at each EMS sector (treatment, triage, transportation). This is for several reasons:

1. To provide site security so that media and onlookers do not mingle with the wounded and interfere with their care.

2. To monitor all victims in the event the perpetrator or an accomplice (such as a look-out or secondary attacker) may be among the injured.

3. To canvas witnesses who may have valuable information.

Words of Wisdom

You are of no help to the public if you become a patient. More importantly, once you become a victim of the event, you place an additional burden on your fellow responders, who must treat you. Assess the scene and resist the urge to run in and help (do not develop tunnel vision). You may place your life and your partner in danger. Remember… do not become a victim.

Paramedics should fully comply with all law enforcement requests because they may be safety-related, or be intended to thwart additional planned attacks. Investigators may interview patients during triage or treatment, or ride along with them to the hospital to gather information on what they saw or know.

Secondary Device or Event (Reassessing Scene Safety)

Terrorists have been known to plant additional explosives that are set to explode after the initial bomb. This type of secondary device is intended primarily to injure responders and to secure media coverage, because the media generally arrives on scene just after the initial response. Do not rely on others to secure your safety. It is every paramedic’s responsibility to constantly assess and reassess the scene for safety. It is easy to overlook a suspicious package lying on the floor while you are treating casualties. Stay alert. Something as subtle as a change in the wind direction during a gas attack or an increase in the number of contaminated patients can place you in danger. Never become so involved with the tasks that you are performing that you do not look around and make sure that the scene remains safe.

i Weapons of Mass Destruction

A weapon of mass destruction (WMD) is anything used as a weapon designed to bring about mass death, casualties, and/or massive damage to property and infrastructure (bridges, tunnels, airports, and seaports). WMDs can be grouped into four major categories: explosive/incendiary devices, chemical, biologic, and radiologic/nuclear weapons and can include poison gas, grenades, rockets or missiles with a propellant charge or explosive, or a mine or similar device. To date, the preferred WMD for terrorists has been explosive devices. Terrorist groups have favored tactics that use truck or car bombs or pedestrian suicide bombers. Previous terrorist attempts to use either chemical or biologic weapons to their full capacity have been unsuccessful. Nonetheless, as a paramedic you should understand the destructive potential of these weapons, and be aware of the clinical symptomology that patients who have been exposed or infected with them may present with.

As discussed earlier, the motives and tactics of new-age terrorist groups have begun to change. As with doomsday cults, many terrorist groups participate in apocalyptic, indiscriminate killing. This doctrine of total carnage would make the use of WMDs highly desirable. WMDs are easy to obtain or create and are specifically geared toward killing large numbers of people. Had the proper techniques been used during the 1995 attack on the Tokyo subway, there may have been tens of thousands of casualties. With the fall of the former Soviet Union, the technology and expertise to produce WMDs may be available to terrorist groups with sufficient funding. Moreover, the technical recipes for making nuclear, biologic, and chemical (NBC) weapons and explosive devices can be found readily on the Internet; in fact, they have even been published on terrorist group websites.

The following sections describe the categories of WMDs that EMS personnel and their agencies should prepare to encounter in the field.

i Explosives/Incendiary Weapons

Explosives are the most common weapon used by terrorists today Figure 8. Incendiary weapons involve agents and chemicals used to start fires. Incendiary agents, such as acetone, can be combined with chemicals to produce explosives capable of massive destruction. Ranging from suicide bombings on public buses to trucks loaded with explosives set to go off in underground parking garages of government buildings, these explosions can be destructive.

imag

Figure 8 Every year, thousands of pounds of explosives are stolen.

i Ammonium Nitrate or “Fertilizer” Bombs

Ammonium nitrate is used commonly as an industrial-grade fertilizer that is not in itself dangerous to handle or transport. Yet in many regions, its sale and purchase requires a special license because when it is mixed with fuel such as diesel, and other easy to acquire components, it forms an extremely explosive compound. The attack on the Alfred P. Murrah Federal Building in Oklahoma City in 1995 (one of the deadliest terrorist attacks in the US) involved a homemade explosive device made from an ammonium nitrate and fuel oil mixture (ANFO). The perpetrators of that incident packed a van with 7,000 lb of ANFO to destroy the Alfred P. Murrah Federal Building and severely damage most buildings in the immediate vicinity. In 1993, Al Qaeda attacked the World Trade Center using an ANFO bomb, killing six people and wounding over 1,000.

i Suicide Bombers (Human Bombs)

Suicide bombers are by far the weapon of choice for modern-day terrorists. This concept merges the destructive power of military-grade explosives with the timing and accuracy of human guidance and triggering Figure 9. They are a low-cost, low-technology, and low-risk weapon. Weapons used by suicide bombers are easily concealed, carried, and delivered with accuracy to a selected target. Recruits for suicide bomb terrorism are readily available; they require little training and are generally deeply committed to killing others as well as themselves. In addition to men, women and children have acted as suicide bombers, making them even more difficult to prevent. Suicide bombers rely on the element of surprise and familiarity with the targeted area.

imag

Figure 9 A suicide bomber merges the destructive power of explosives with human guidance and triggering.

In addition to their tactical advantages, suicide bombers’ attacks are occasionally recorded by the terrorist organization as propaganda and to perpetuate fear in the population. Outside of the United States, media outlets exhibit little self-censorship and often broadcast graphic terrorist attacks and videos made by terrorists. This helps to spread the message of terror.

Words of Wisdom

REMEMBER: Two of the most common blast injuries are tympanic membrane rupture and barotraumas (damage to the structures of the inner ear). These types of injures make it difficult or impossible to communicate with patients who have been near a bomb blast because they may be disoriented from vertigo (as a result of inner ear damage) or have a greatly diminished or absent hearing. You will need to be aware of this when triaging and treating these patients because patients may not respond as expected to questions or the situation that they are in.

i Chemical Agents

Chemical agents are man-made substances that can have devastating effects on living organisms. They can be produced in liquid, powder, or vapor form depending on the desired route of exposure and dissemination technique and are dispersed to kill or injure. First developed during World War I, these agents have been implicated in thousands of deaths since being introduced on the battlefield, and since then have been used to terrorize civilian populations. These agents can be categorized as follows:

i Vesicants or blister agents (eg, mustard gas and lewisite)

i Respiratory or choking agents (eg, phosgene or chlorine)

i Nerve agents (eg, sarin, soman, tabun, or V agent)

i Metabolic or blood agents (eg, hydrogen cyanide, cyanogen chloride)

i Irritating agents (eg, mace, chloropicrin, tear gas, capsicum/pepper spray, and dibenzoxazepine)

During the Cold War, many of these agents were perfected and stockpiled. Whereas the United States has long renounced the use of chemical weapons, many nations still develop and stockpile them. These agents are deadly and pose a threat if acquired by terrorists.

Chemical weapons have several classifications. The properties or characteristics of an agent can be described as liquid, gas, or solid material. Persistency and volatility are terms used to describe how long the agent will stay on a surface before it evaporates. Persistent or nonvolatile agents can remain on a surface for long periods of time, usually longer than 24 hours. Nonpersistent or volatile agents evaporate relatively fast when left on a surface in the optimal temperature range. An agent that is described as highly persistent (such as VX, a nerve agent) can remain in the environment for weeks to months, whereas an agent that is highly volatile (such as sarin, also a nerve agent) will turn from liquid to gas (evaporate) within minutes to seconds.

Route of exposure is a term used to describe how the agent most effectively enters the body. Chemical agents can have either a vapor or contact hazard. Agents with a vapor hazard enter the body through the respiratory tract in the form of vapors. Agents with a contact hazard (or skin hazard) give off little vapor or no vapors and enter the body through the skin.

i Vesicants (Blister Agents)

The primary route of exposure of blister agents, or vesicants, is the skin (contact); however, if vesicants are left on the skin or clothing long enough, they produce vapors that can enter the respiratory tract. Vesicants cause burn-like blisters to form on the patient’s skin as well as in the respiratory tract. The vesicant agents consist of sulfur mustard (H), lewisite (L), and phosgene oxime (CX) (the symbols H, L, and CX are military designations for these chemicals). The vesicants usually cause the most damage to damp or moist areas of the body, such as the armpits, groin, and respiratory tract. Signs of vesicant exposure on the skin include the following:

i Skin irritation, burning, and reddening

i Immediate intense skin pain (with L and CX)

i Formation of large blisters

i Gray discoloration of skin (a sign of permanent damage seen with L and CX)

i Swollen and closed or irritated eyes

i Permanent eye injury (including blindness)

If vapors were inhaled, the patient may experience the following:

i Hoarseness and stridor

i Severe cough

i Hemoptysis (coughing up of blood)

i Severe dyspnea

Sulfur mustard (agent H) is a brownish, yellowish oily substance that is generally considered persistent. When released, sulfur mustard has the distinct smell of garlic or mustard and is quickly absorbed into the skin and/or mucous membranes. As the agent is absorbed into the skin, it begins an irreversible process of damage to the cells. Absorption through the skin or mucous membranes usually occurs within seconds, and damage to the underlying cells takes place within 1 to 2 minutes.

Sulfur mustard is considered a mutagen, which means that it mutates, damages, and changes the structures of cells. Eventually, cellular death will occur. On the surface, the patient will generally not produce any signs or symptoms until 4 to 6 hours after exposure (depending on concentration and amount of exposure) Figure 10.

The patient will experience a progressive reddening of the affected area, which will gradually develop into large blisters. These blisters are similar in shape and appearance to those associated with thermal second-degree burns. The fluid within the blisters does not contain any of the agent; however, the skin covering the area is considered to be contaminated until decontamination by trained personnel has been performed.

Sulfur mustard also attacks vulnerable cells within the bone marrow and depletes the body’s ability to reproduce white blood cells. As with burns, the primary complication associated with vesicant blisters is secondary infection. If the patient does survive the initial direct injury from the agent, the depletion of the white blood cells leaves the patient with a decreased resistance to infections. Although sulfur mustard is regarded as persistent, it does release enough vapors when dispersed to be inhaled. This creates upper and lower airway compromise. The result is damage and swelling of the airways. The airway compromise makes the patient’s condition far more serious.

imag

Figure 10 Skin damage resulting from exposure to sulfur mustard (agent H).

Lewisite (L) and phosgene oxime (CX) produce blister wounds similar to sulfur mustard. They are highly volatile and have a rapid onset of symptoms, as opposed to the delayed onset seen with sulfur mustard. These agents produce immediate intense pain and discomfort when contact is made. The patient may have a grayish discoloration at the contaminated site. While tissue damage also occurs with exposure to these agents, they do not cause the secondary cellular injury that is associated with sulfur mustard.

Vesicant Agent Treatment

There are no antidotes for sulfur mustard or CX exposure. BAL (British Anti-Lewisite) is the antidote for agent L; however, it is not carried by civilian EMS. You must ensure that the patient has been decontaminated (usually by soap and copious amounts of water) before ABCs are initiated. The patient may require prompt airway support if any agent has been inhaled, but this should not occur until after decontamination. Initiate transport and gain IV access as soon as possible. Generally, burn centers are best equipped to handle the wounds and subsequent infections produced by vesicants. Follow your local protocols when you are deciding what facility to transport the patient to.

i Pulmonary Agents (Choking Agents)

The pulmonary agents are gases that cause immediate harm to persons exposed to them. The primary route of exposure for these agents is through the respiratory tract, which makes them an inhalation or vapor hazard. Once inside the lungs, they damage the lung tissue and fluid leaks into the lungs. Pulmonary edema develops in the patient, resulting in difficulty breathing due to the inability for air exchange. These agents produce respiratory-related symptoms such as dyspnea, tachypnea, and pulmonary edema. This class of chemical agents consists of chlorine (CL) and phosgene.

CL was the first chemical agent ever used in warfare. It has a distinct odor of bleach and creates a green haze when released as a gas. Initially it produces upper airway irritation and a choking sensation. The patient may later experience the following signs and symptoms:

i Shortness of breath

i Chest tightness

i Hoarseness and stridor due to upper airway constriction

i Gasping and coughing

With serious exposures, patients may experience pulmonary edema, complete airway constriction, and death. The fumes from a mixture of household bleach (CL) and ammonia create an acid gas that produces similar effects. Each year, such mixtures overcome hundreds of people when they try to mix household cleaners.

Phosgene should not be confused with phosgene oxime, a blistering agent, or vesicant. Not only has phosgene been produced for chemical warfare, but it is a product of combustion such as might be produced in a fire at a textile factory or house, or from metalwork or burning Freon (a liquid chemical used in refrigeration). Therefore, you may encounter a patient who was exposed to this gas during the course of a normal call or at a fire scene. Phosgene is a potent agent that has a delayed onset of symptoms, usually hours. Unlike CL, when phosgene enters the body, it generally does not produce severe irritation that might possibly cause the patient to leave the area or hold his or her breath. In fact, the odor produced by the chemical is similar to that of freshly mown grass or hay. The result is that much more of the gas is allowed to enter the body unnoticed. The initial symptoms of a mild exposure may include the following signs and symptoms:

i Nausea

i Chest tightness

i Severe cough

i Dyspnea on exertion

The patient with a severe exposure may present with dyspnea at rest and excessive pulmonary edema (the patient will actually expel large amounts of fluid from their lungs). The pulmonary edema that is seen with a severe exposure produces such large amounts of fluid from the lungs that the patient may actually become hypovolemic and subsequently hypotensive.

Pulmonary Agent Treatment

The best initial treatment for any pulmonary agent is to remove the patient from the contaminated atmosphere. This should be done by trained personnel in the proper PPE. Aggressive management of the ABCs should be initiated, paying particular attention to oxygenation, ventilation, and suctioning if required. Do not allow the patient to be active because this will worsen the condition much faster. There are no antidotes to counteract the pulmonary agents. Performing the ABCs, gaining IV access, allowing the patient to rest in a position of comfort with the head elevated, and initiating rapid transport are the primary goals for care provided in the prehospital setting. Pharmacotherapy of this patient may include the standard treatment for bronchospasm, pulmonary edema, potential corticosteroid use (per local medical direction), and positive-pressure ventilation with supplementary oxygen.

i Nerve Agents

The nerve agents are among the most deadly chemicals developed. Designed to kill large numbers of people with small quantities, nerve agents can cause cardiac arrest within seconds to minutes of exposure. Nerve agents, discovered while in search of a superior pesticide, are a class of chemical called organophosphates, which are found in household bug sprays, agricultural pesticides, and some industrial chemicals, at far lower strengths than in nerve agents.

There are almost 900 different pesticides available for use in the United States. Approximately 37 of these belong to a class of insecticides known as organophosphates. The chemicals in this class kill insects by disrupting their brains and nervous systems. Unfortunately, these chemicals or nerve agents (at greater strengths) also can harm the brains and nervous systems of animals and humans. These chemicals block the essential enzyme in the nervous system called cholinesterase from working, causing the body’s organs to become overstimulated and burn out.

G agents came from the early nerve agents, the G series, which were developed by German scientists (hence the G) in the period after WWI and into WWII. There are three G series agents, which are all designed with the same basic chemical structure with slight variations to produce different properties. The two variations of these agents are lethality and volatility.

YOU are the Medic   PART 3

While you are performing your primary assessment, the sector leader informs you that the HazMat team located an empty gas cylinder by the air intake of the air conditioning system and has confirmed the presence of cyanide. A few people from inside the courthouse described the odor as “almond-like.” You obtain IV access in the right antecubital space with an 18-gauge angiocath and hang a bag of normal saline running it to keep the vein open. Before you can prepare any medications, the patient becomes unresponsive and hypotensive.

Recording Time: 10 Minutes

Respirations

18 breaths/min, shallow

Pulse

Radial pulse, 116 beats/min, regular and weak

Skin

Pink, warm, dry

Blood pressure

92/56 mm Hg

Oxyqen saturation (SpO2)

96% on 15 L/min nonrebreathing mask

Pupils

Dilated, equal, and slow to react

5. Will the smell of almonds always be present with a cyanide exposure?

The following G agents are listed from high volatility to low volatility:

i Sarin (GB). Highly volatile colorless and odorless liquid. Turns from liquid to gas within seconds to minutes at room temperature. Highly lethal, with an LD50 of 1,700 mg/70 kg (about 1 drop, depending on the purity). The LD50 is the amount that will kill 50% of people who are exposed to this level. GB is primarily a vapor hazard, with the respiratory tract as the main route of entry. This agent is especially dangerous in enclosed environments such as office buildings, shopping malls, or subway cars. When this agent comes into contact with skin, it is quickly absorbed and evaporates. When GB is on clothing, it has the effect of off-gassing, which means that the vapors are continuously released over a period of time (like perfume). This renders the patient as well as the patient’s clothing contaminated.

i Soman (GD). Twice as persistent as GB and five times as lethal. It has a fruity odor as a result of the type of alcohol used in the agent and generally has no color. GD is both a contact and inhalation hazard that can enter the body through skin absorption and through the respiratory tract. A unique additive in GD causes it to bind to the cells so that it attacks faster than any other agent. This irreversible binding is called aging, which makes it more difficult to treat patients who have been exposed.

i Tabun (GA). Approximately half as lethal as GB and 36 times more persistent; under the proper conditions, it will remain for several days. It also has a fruity smell and an appearance similar to GB. The components used to manufacture GA are easy to acquire and the agent is easy to manufacture, which make it unique. GA is both a contact and inhalation hazard that can enter the body through skin absorption as well as through the respiratory tract.

i V agent (VX). Clear oily agent that has no odor and looks like baby oil. VX was developed by the British after WWII and has similar chemical properties to the G series agents. The difference is that VX is over 100 times more lethal than GB and is extremely persistent Figure 11. In fact, VX is so persistent that given the proper conditions it will remain relatively unchanged for weeks to months. These properties make VX primarily a contact hazard because it lets off little vapor. It is easily absorbed into the skin, and the oily residue that remains on the skin’s surface is extremely difficult to decontaminate.

Nerve agents all produce similar symptoms but have varying routes of entry. Nerve agents differ slightly in lethal concentration or dose and also differ in their volatility. Some agents are designed to become a gas quickly (nonpersistent or highly volatile), whereas others remain liquid for a period of time (persistent or nonvolatile). These agents have been used successfully in warfare and to date represent the only type of chemical agent that has been used successfully in a terrorist act. Once the agent has entered the body through skin contact or through the respiratory system, the patient will begin to exhibit a pattern of predictable symptoms. Like all chemical agents, the severity of the symptoms will depend on the route of exposure and the amount of agent to which the patient was exposed. The resulting symptoms are described using the military mnemonic SLUDGEM and the medical mnemonic DUMBELS. These two mnemonics are used to describe the symptoms of nerve agent exposure and are shown in Table 1. The medical mnemonic is more useful to you because it lists the more dangerous symptoms associated with exposure to nerve agents.

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Figure 11 VX is the most toxic chemical ever produced. The dot on the penny demonstrates the amount needed to achieve the lethal dose.

There are only a handful of medical conditions that are associated with the bilateral pinpoint constricted pupils (miosis) seen with nerve agent exposure. Conditions such as a suspected stroke, basilar skull fracture, direct light to both eyes, and an opiate drug overdose all can cause bilateral constricted pupils. You should therefore assess the patient for all of the SLUDGEM/DUMBELS signs and symptoms to determine whether the patient has been exposed to a nerve agent.

Miosis is the most common symptom of nerve agent exposure and can remain for days to weeks. This symptom, along with the others listed in Table 1, will help you recognize exposure to a nerve agent early. The seizures that are associated with nerve agent exposure are unlike those found in patients with a history of seizure. The patient will continue to seize until death or until treatment is given with a nerve agent antidote (DuoDote or MARK 1).

Table 1 Symptoms of Persons Exposed to Nerve Agents

Military Mnemonic: SLUDGEM

S

Salivation

L

Lacrimation

U

Urination

D

Defecation

G

GI distress

E

Emesis

M

Miosis

Medical Mnemonic: DUMBELS

D

Defecation

U

Urination

M

Miosis

B

Bradycardia, Bronchorrhea

E

Emesis

L

Lacrimation

S

Salivation

Nerve Agent Treatment

Fatalities from severe exposure occur as a result of respiratory complications, which lead to respiratory arrest. Once the patient has been decontaminated, you should be prepared to treat these patients aggressively, if they are to be saved. You can greatly increase the patient’s chances of survival simply by providing airway and ventilatory support. As with all emergencies, managing the ABCs is the best and most important treatment that you can provide. Often patients exposed to these agents will begin seizing and will not stop. These patients will require administration of nerve agent antidote kits in addition to support of the ABCs.

Fortunately, there is an antidote for nerve agent exposure. The DuoDote Antidote Kit contains a single injection of both atropine (2 mg) and 2-PAM chloride (pralidoxime chloride) (600 mg). You may also have access to a MARK 1 kit, also known as Nerve Agent Antidote Kits (NAAK), but these kits are no longer made. The MARK 1 kit contains the same medications that are in the DuoDote Antidote Kit (atropine and 2-PAM chloride), but they are administered with two separate auto-injectors. In some regions, paramedics may carry DuoDote or MARK 1 kit on the unit and will be called on to administer it. These medications are delivered using the same technique as the EpiPen auto-injector; however, multiple doses may need to be administered. Also, a benzodiazepine may need to be administered due to the concurrent seizure activity.

Atropine is used to block the nerve agent’s overstimulation of the body. However, because the nerve agent may remain in the body for long periods of time, 2-PAM chloride is used to eliminate the agent from the body. The 2-PAM antidote is effective at relieving the respiratory muscle paralysis and twitching caused by the nerve agent. Many of the symptoms described in the DUMBELS mnemonic will be reversed with the use of atropine; however, many doses may need to be administered to see these results. If your service carries a NAAK, please refer to your medical director and local protocols for dose and usage information.

Words of Wisdom

On March 20th, 1995, members of a Japanese cult released sarin (GB) in the Tokyo subway. The first arriving medical responders were met with chaos as hundreds and then thousands of people fled the subway system. Many were contaminated and showing signs and symptoms of nerve agent exposure. In the end, more than 5,000 people sought medical care for exposure to sarin, and 12 people died. None of the EMS personnel wore protective clothing and most became cross-contaminated. Remember, you can avoid becoming exposed. Do not become a victim yourself!

Table 2 has been provided for quick reference and comparison of the nerve agents.

i Industrial Chemicals/Insecticides

As previously mentioned, the basic chemical ingredient in nerve agents is organophosphate. This is a common chemical that is used in lesser concentrations for insecticides. Whereas industrial chemicals do not possess sufficient lethality to be effective WMDs, they are easy to acquire, inexpensive, and would have similar effects as the nerve agents. Crop-duster planes could be used to disseminate these chemicals. You should be cautious when you are responding to calls where insecticide equipment is stored and used, such as a farm or supply store that sells these products. The symptoms and medical management of patients poisoned by organophosphate insecticide are identical to those of the nerve agents.

Metabolic Agents (Cyanides)

Hydrogen cyanide (AC) and cyanogen chloride (CK) are both agents that affect the body’s ability to use oxygen. Cyanide is a colorless gas that has an odor similar to almonds. The effects of the cyanides begin on the cellular level and are rapidly seen at the organ system level. Beside the nerve agents, metabolic agents are the only chemical weapons known to kill within seconds to minutes. Unlike nerve agents, however, these deadly gases are commonly found in many industrial settings. Cyanides are produced in massive quantities throughout the United States every year for industrial uses such as gold and silver mining, photography, lethal injections, and plastics processing. They are often present in fires associated with textile or plastic factories. In fact, cyanide is naturally found in the pits of many fruits in low doses. There is little difference in the symptoms found between AC and CK. In low doses, these chemicals are associated with dizziness, light-headedness, headache, and vomiting. Higher doses will produce symptoms that include the following:

Table 2 Nerve Agents

imag

i Shortness of breath and gasping respirations

i Tachypnea

i Flushed skin color

i Tachycardia

i Altered mental status

i Seizures

i Coma

i Apnea

i Cardiac arrest

Words of Wisdom

Always make sure your patients have been thoroughly decontaminated by trained personnel before you come into contact with them. Chemical agents are primarily a vapor hazard, and all of the patient’s clothing must be removed to prevent off-gassing. Finally, never perform mouth-to-mouth or mouth-to-mask ventilation on a victim of a chemical agent. Many of the vapors may linger in the patient’s airway, and cross-contamination may occur.

The symptoms associated with the inhalation of a large amount of cyanide will all appear within several minutes. Death is likely unless the patient is treated promptly.

Cyanide Agent Treatment Cyanide binds with the body’s cells, preventing oxygen from being used. Several medications act as antidotes, but many services do not carry them. Once trained personnel wearing the proper PPE have removed the patient from the source of exposure, even if there is no liquid contamination, all of the patient’s clothes must be removed to prevent off-gassing in the ambulance. Trained and protected personnel must decontaminate any patients who may have been exposed to liquid contamination before you can initiate treatment. Then you should support the patient’s ABCs and gain IV access. Mild effects of cyanide exposure will generally resolve by simply removing the victim from the source of contamination and administering supplementary oxygen. Severe exposure, however, will require aggressive oxygenation and perhaps ventilation with supplementary oxygen. Always use a bag-mask device or oxygen-powered ventilator device to ventilate a patient exposed to a metabolic agent. The agent can easily be passed on from the patient to you through mouth-to-mouth or mouth-to-mask ventilations. If no antidote is available, initiate transport immediately.

Table 3 summarizes the chemical agents. The odors of the particular chemicals are provided for informational purposes only. The sense of smell is a poor tool to use to determine whether there is a chemical agent present. Many persons are unable to smell the agents, and the odor could be derived from another source. This information is useful to you if you receive reports from victims claiming to smell bleach or garlic, for example. You should never enter a potentially hazardous area and “smell” to determine whether a chemical agent is present.

i Biologic Agents

Biologic agents are organisms that cause disease or death. They are generally found in nature; for terrorist use, however, they are cultivated, synthesized, and mutated in a laboratory. The weaponization of biologic agents is performed to artificially maximize the target population’s exposure to the germ, thereby exposing the greatest number of people and achieving the desired result.

The primary types of biologic agents that you may come into contact with during a biologic event include the following:

i Viruses

i Bacteria

i Neurotoxins

Biologic agents pose many difficult issues when used as a WMD. Biologic agents can be almost completely undetectable. Also, most of the diseases caused by these agents will be similar to other minor illnesses commonly seen by paramedics.

Biologic agents may be spread in various ways. Dissemination is the means by which a terrorist will spread the agent—for example, poisoning the water supply or aerosolizing the agent into the air or ventilation system of a building. A disease vector is an animal that spreads disease, once infected, to another animal. For example, the plague can be spread by infected rats, smallpox by infected persons, and West Nile virus by infected mosquitoes. How easily the disease is able to spread from one human to another human is called communicability. Some diseases, such as those caused by human immunodeficiency virus (HIV), are difficult to spread by routine contact. Therefore, communicability is considered low. In other instances when communicability is high, such as with smallpox, the person is considered contagious. Typically, your standard precautions are enough to prevent contamination from contagious biologic organisms.

Incubation describes the period of time between the person becoming exposed to the agent and when symptoms begin. The incubation period is especially important for you to understand. Although your patient may not exhibit signs or symptoms, he or she may be contagious.

You need to be aware of when you should suspect the use of biologic agents. If the agent is in the form of a powder, such as in the October 2001 incidents involving anthrax powder mailed in letters, the call must be handled by HazMat specialists. Patients who have come into direct contact with the agent need to be decontaminated before any EMS contact or treatment is initiated.

Table 3 Chemical Agents

imag

i Viruses

Viruses are germs that require a living host to multiply and survive. A virus is a simple organism and cannot thrive outside of a host (living body). Once in the body, the virus will invade healthy cells and replicate itself to spread through the host. As the virus spreads, so does the disease that it carries. Viruses survive by moving from one host to another by using its transport system—vectors.

Viral agents that may be used during a biologic terrorist release pose an extraordinary problem for health care providers, especially those in EMS. Although some viral agents do have vaccines, there is no treatment for a viral infection other than antivirals for some agents. Because of this characteristic, the following viruses have been used as terrorist agents.

Smallpox

Smallpox is a highly contagious disease. All forms of standard precautions must be used to prevent cross-contamination to health care providers. Simply by wearing examination gloves, a HEPA-filtered respirator, and eye protection, you will greatly reduce your risk of contamination. The last natural case of smallpox in the world was seen in 1977. Before the rash and blisters show, the illness will start with a high fever and body aches and headaches. The patient’s temperature is usually in the range of 101°F to 104°F.

An easy, quick way to differentiate the smallpox rash from other skin disorders is to observe the size, shape, and location of the lesions. In smallpox, all the lesions are identical in their development. In other skin disorders, the lesions will be in various stages of healing and development. Smallpox blisters also begin on the face and extremities and eventually move toward the chest and abdomen. The disease is in its most contagious phase when the blisters begin to form Figure 12. Unprotected contact with these blisters will promote transmission of the disease. There is a vaccine to prevent smallpox; however, it has been linked to medical complications and in rare cases, death Table 4. Vaccination against the disease is part of a national strategy to respond to a terrorist threat. Because the vaccine does have some risk, only first responders have been offered the vaccine. Should an outbreak occur, the vaccine would be offered to people at risk.

Viral Hemorrhagic Fevers

Viral hemorrhagic fevers (VHFs) consist of a group of diseases that include the Ebola, Rift Valley, and yellow fever viruses, among others. This group of viruses causes the blood in the body to seep out from the tissues and blood vessels Figure 13. Initially, the patient will have flu-like symptoms, progressing to more serious symptoms such as internal and external hemorrhaging. Outbreaks are not uncommon in Africa and South America. Outbreaks in the United States, however, are extremely rare. All standard precautions must be taken when you are treating these illnesses. Mortality rates can range from 5% to 90%, depending on the strain of virus, the patient’s age and health condition, and the availability of a modern health care system Table 5.

i Bacteria

Unlike viruses, bacteria do not require a host to multiply and live. Bacteria are much more complex and larger than viruses and can grow up to 100 times larger than the largest virus. Bacteria contain all the cellular structures of a normal cell and are completely self-sufficient. Most importantly, bacterial infections can be fought with antibiotics.

imag

Figure 12 In smallpox, all the lesions are identical in their development. In other skin disorders, the lesions will be in various stages of healing and development.

Table 4 Characteristics of Smallpox

Dissemination

Aerosolized for warfare or terrorist uses

Communicability

High from infected persons or items (such as blankets used by infected patients). Person-to-person transmission is possible.

Route of entry

Through inhalation of coughed droplets or direct skin contact with blisters.

Signs and symptoms

Severe fever, malaise, body aches, headaches, small blisters on the skin, bleeding of the skin and mucous membranes. Incubation period is 10 to 12 days and the duration of the illness is approximately 4 weeks.

Medical management

Standard precautions. There is no specific treatment for smallpox victims. Patients should be provided with supportive care (ABCs).

YOU are the Medic   PART 4

Your partner provides positive-pressure ventilation with a bag-mask device attached to 100% oxygen while you increase the flow of the IV line and prepare for intubation. The patient’s airway is secured with a 7.5-mm ETT. Tube placement is confirmed with waveform capnography and the patient is manually ventilated by your partner. Per your protocols, you mix 5 g of hydroxocobalamin into a 250-mL bag of normal saline and set it to run over 15 minutes. After the hydroxocobalamin infusion is finished, you help prepare the patient for transport.

Recording Time: 15 Minutes

Respirations

12 breaths/min, adequate depth and volume, manual ventilation

Pulse

Radial pulse, 114 beats/min, regular and weak

Skin

Pink, warm, and dry

Blood pressure

96/60 mm Hg

Oxygen saturation (SpO2)

96% on 100% oxygen via bag-mask

Pupils

Dilated, equal, and slow to respond

6. What is the treatment of choice for a patient with cyanide toxicity?

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Figure 13 Viral hemorrhagic fevers cause the blood vessels and tissues to seep blood. The end result is ecchymosis, hemoptysis, and blood in the patient’s stool. Notice the severe discoloration in this patient with Crimean Congo hemorrhagic fever, indicating internal bleeding.

Table 5 Characteristics of Viral Hemorrhagic Fevers

Dissemination

Direct contact with an infected person’s body fluids. It can also be aerosolized for use in an attack.

Communicability

Moderate from person to person or from contaminated items.

Route of entry

Direct contact with an infected person’s body fluids.

Signs and symptoms

Sudden onset of fever, weakness, muscle pain, headache, and sore throat. All of these symptoms are followed by vomiting and as the virus runs its course, internal and external bleeding.

Medical management

Standard precautions. There is no specific treatment for viral hemorrhagic fever. Patients should be provided supportive care (ABCs) and treatment for shock and hypotension, if present.

Most bacterial infections will generally begin with flu-like symptoms, which make it quite difficult to identify whether the cause is a biologic attack or a natural epidemic. Biologic agents have been developed and used for centuries during times of war.

Inhalation and Cutaneous Anthrax (Bacillus anthracis)

Anthrax is a deadly bacterium that lies dormant in a spore (protective shell). When exposed to the optimal temperature and moisture, the germ will be released from the spore. The routes of entry for anthrax are inhalation, cutaneous, or gastrointestinal (from consuming food that contain spores) Figure 14.

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Figure 14 Cutaneous anthrax.

The inhalational form or pulmonary anthrax is the most deadly and often presents as a severe cold. Pulmonary anthrax infections are associated with a 90% death rate if untreated. Antibiotics can be used to treat anthrax successfully. There is also a vaccine to prevent anthrax infections Table 6.

Plague—Bubonic/Pneumonic

Of all the infectious diseases known to humans, none has killed as many as the plague. The 14th century plague that ravaged Asia, the Middle East, and finally Europe (the Black Death) killed an estimated 33 to 42 million people. Later on, in the early 19th century, almost 20 million people in India and China perished due to the plague. The plague’s natural vectors are infected rodents and fleas. When a person is either bitten by an infected flea or comes into contact with an infected rodent (or the waste of the rodent), that person can contract bubonic plague.

Bubonic plague infects the lymphatic system (a passive circulatory system in the body that bathes the tissues in lymph and works with the immune system). When this occurs, the patient’s lymph nodes (area of the lymphatic system where infection-fighting cells are housed) become infected and grow. The glands of the nodes will grow large (up to the size of a tennis ball) and round, forming buboes Figure 15. If left untreated, the infection may spread through the body, leading to sepsis and possibly death. This form of plague is not contagious and is not likely to be seen in a bioterrorist incident.

Table 6 Characteristics of Anthrax

Dissemination

Aerosol

Communicability

Only in the cutaneous form (rare)

Route of entry

Through inhalation of spore or skin contact with spore or direct contact with skin wound (cutaneous)

Signs and symptoms

Flu-like symptoms, fever, respiratory distress with tachycardia, shock, pulmonary edema and respiratory failure after 3 to 5 days of flu-like symptoms

Medical management

Pulmonary/inhalation: Standard precautions, supplemental oxygen, ventilatory support for pulmonary edema or respiratory failure, and transport. Cutaneous: Standard precautions, apply dry sterile dressing to prevent accidental contact with wound and fluids.

Pneumonic plague is a lung infection, also known as plague pneumonia, which results from inhalation of plague bacteria. This form of the disease is contagious and has a much higher death rate than the bubonic form. This form of plague therefore would be easier to disseminate (aerosolized), has a higher mortality rate and is contagious Table 7.

i Neurotoxins

Neurotoxins are the most deadly substances known to humans. The strongest neurotoxin is 15,000 times more lethal than VX and 100,000 times more lethal than GB. These toxins are produced from plants, marine animals, molds, and bacteria. The route of entry for these toxins is through ingestion, inhalation from aerosols, or injection. Unlike viruses and bacteria, neurotoxins are not contagious and have a faster onset of symptoms. Although these biologic toxins have immense destructive potential, they have not been used successfully as a WMD.

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Figure 15 A. Plague buboe at lymph node under arm. B. Plague buboe at lymph node on neck.

Table 7 Characteristics of Plague

Dissemination

Aerosol

Communicability

Bubonic: Low, only from contact with fluid in buboe
Pneumonic: High, from person to person

Route of entry

Ingestion, inhalation, or cutaneous

Signs and symptoms

Fever, headache, muscle pain and tenderness, pneumonia, shortness of breath, extreme lymph node pain and enlargement (bubonic)

Medical management

Standard precautions, ABCs, provide supplemental oxygen, and transport

Botulinum Toxin

The most potent neurotoxin is botulinum, which is produced by bacteria. When introduced into the body, this neurotoxin affects the nervous system’s ability to function. Voluntary muscle control will diminish as the toxin spreads. Eventually the toxin will cause muscle paralysis that begins at the head and face and travels downward throughout the body. The patient’s accessory muscles and diaphragm will become paralyzed, and the patient will go into respiratory arrest Table 8.

Ricin

While not as deadly as botulinum, ricin is still five times more lethal than VX. This toxin is derived from mash that is left from the castor bean Figure 16. When introduced into the body, ricin causes pulmonary edema and respiratory and circulatory failure, leading to death Table 9.

The clinical picture depends on the route of exposure. The toxin is quite stable and extremely toxic by many routes of exposure, including inhalation. Perhaps 1 to 3 mg of ricin can kill an adult, and the ingestion of one seed can probably kill a child.

Table 8 Characteristics of Botulinum Toxin

Dissemination

Aerosol or food supply sabotage or injection

Communicability

None

Route of entry

Ingestion or gastrointestinal

Signs and symptoms

Dry mouth, intestinal obstruction, urinary retention, constipation, nausea and vomiting, abnormal pupil dilation, blurred vision, double vision, drooping eyelids, difficulty swallowing, difficulty speaking, and respiratory failure due to paralysis

Medical management

ABCs, provide supplemental oxygen, and transport. Ventilatory support may be needed due to paralysis of the respiratory muscles. A vaccine is available.

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Figure 16 These seemingly harmless castor beans contain the key ingredient for ricin, one of the most potent toxins known to humans.

Table 9 Characteristics of Ricin

Dissemination

Aerosol or contamination of a food or water supply by sabotage

Communicability

None

Route of entry

Inhalation, ingestion, injection

Signs and symptoms

Inhaled: Cough, difficulty breathing, chest tightness, nausea, muscle aches, pulmonary edema, and hypoxia Ingested: Nausea and vomiting, internal bleeding, and death Injection: No signs except swelling at the injection site and death

Medical management

ABCs. No treatment or vaccine exists.

Although all parts of the castor bean are actually poisonous, it is the seeds that are the most toxic. Castor bean ingestion causes a rapid onset of nausea, vomiting, abdominal cramps, and severe diarrhea, followed by vascular collapse. Death usually occurs on the third day in the absence of appropriate medical intervention.

Ricin is least toxic by the oral route. This is probably a result of poor absorption in the gastrointestinal tract, some digestion in the gut, and, possibly, some expulsion of the agent as caused by the rapid onset of vomiting. Ingestion causes local hemorrhage and necrosis of the liver, spleen, kidneys, and gastrointestinal tract. Signs and symptoms appear 4 to 8 hours after exposure.

Signs and symptoms of ricin ingestion are as follows:

i Fever

i Chills

i Headache

i Muscle aches

i Nausea

i Vomiting

i Diarrhea

i Severe abdominal cramping

i Dehydration

i Gastrointestinal bleeding

i Necrosis of liver, spleen, kidneys, and gastrointestinal tract

Inhalation of ricin causes nonspecific weakness, cough, fever, hypothermia, and hypotension. Symptoms occur about 4 to 8 hours after inhalation, depending on the inhaled dose. The onset of profuse sweating some hours later signifies the termination of the symptoms.

Signs and symptoms of ricin inhalation are as follows:

i Fever

i Chills

i Nausea

i Local irritation of eyes, nose, and throat

i Profuse sweating

i Headache

i Muscle aches

i Nonproductive cough

i Chest pain

i Dyspnea

i Pulmonary edema

i Severe lung inflammation

i Cyanosis

i Convulsions

i Respiratory failure

Treatment is supportive and includes both respiratory support and cardiovascular support as needed. Early intubation, ventilation, and positive end-expiratory pressure, combined with treatment of pulmonary edema, are appropriate. IV fluids and electrolyte replacement are useful for treating the dehydration caused by profound vomiting and diarrhea. Table 10 summarizes the biologic agents.

i Other Paramedic Roles During a Biologic Event

Syndromic Surveillance

Syndromic surveillance is the monitoring, usually by local or state health departments, of patients presenting to emergency departments and alternative care facilities, and the recording of EMS call volume and the use of over-the-counter medications. Patients with signs and symptoms that resemble influenza are particularly important. Local and state health departments monitor for an unusual influx of patients with these symptoms in hopes of discovering an outbreak early. The EMS role in syndromic surveillance is a small one, yet valuable in the overall tracking of a biologic terrorist event or infectious disease outbreak. Quality assurance and dispatch operations need to be aware of an unusual number of calls from patients with “unexplainable flu” coming from a particular region or community.

Table 10 Biologic Agents

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Points of Distribution

Points of distribution (PODs) (Strategic National Stockpile) are strategically placed facilities that have been preestablished for the mass distribution of antibiotics, antidotes, vaccinations, and other medications and supplies. These medications may be delivered in large containers known as “push packs” by the Centers for Disease Control and Prevention Figure 17. These containers have a targeted delivery time of within 12 hours anywhere in the country and contain antibiotics, chemical antidotes, antitoxins, life-support medications, IV administration, airway maintenance supplies, and medical/surgical items. In some regions, local and state municipalities have started to stockpile their own supplies to reduce the time delay.

Paramedics may be called on to assist in the delivery of the medications to the public (depending on local emergency management planning). The paramedic’s role may include triage, treatment of seriously ill patients, and patient transport to the hospital. Most plans for PODs include at least one ambulance on standby for the transport of seriously ill patients.

i Radiologic/Nuclear Devices

There have been only two publicly known incidents involving the use of a nuclear device. During WWII, Hiroshima and Nagasaki were devastated when they were targeted with nuclear bombs. It has been estimated that a death toll of 214,000 people occurred due to the two bombs and their associated effects. The awesome destructive power demonstrated by the attack ended WWII and has since served as a deterrent to nuclear war.

There are also nations that hold close ties with terrorist groups (state-sponsored terrorism) and have obtained some degree of nuclear capability. It is also possible for a terrorist to secure radioactive materials or waste to perpetrate an act of terror. Such materials are far easier for the determined terrorist to acquire and require less expertise to use. The difficulties in developing a nuclear weapon are well documented. Radioactive materials, however, such as those in radiologic dispersal devices (RDDs, discussed later), can cause widespread panic and civil disturbances.

i

Figure 17 The Centers for Disease Control and Prevention Strategic National Stockpile can deliver one of many push packs to any location in the country within 12 hours of an emergency.

i Radiation

Ionizing radiation is energy that is emitted in the form of rays, or particles. This energy can be found in radioactive material, such as rocks and metals. Radioactive material is any material that emits radiation. This material is unstable, and it attempts to stabilize itself by changing its structure in a natural process called decay. As the substance decays, it gives off radiation until it stabilizes. The process of radioactive decay can take from as little as minutes to billions of years; meanwhile, the substance remains radioactive.

The energy that is emitted from a strong radiologic source is either alpha, beta, gamma (x-rays), or neutron radiation Figure 18. Alpha is the least harmful penetrating type of radiation and cannot travel fast or through most objects. In fact, a sheet of paper or the body’s skin easily stops it. Beta radiation is slightly more penetrating than alpha and requires a layer of clothing to stop it. Gamma or x-rays are far faster and stronger than alpha and beta rays. These rays easily penetrate through the human body and require either several inches of lead or concrete to prevent penetration. Neutron energy is the fastest moving and most powerful form of radiation. Neutrons easily penetrate through lead and require several feet of concrete to stop them.

i Sources of Radiologic Material

There are thousands of radioactive materials found on the earth. These materials are generally used for purposes that benefit humankind, such as medicine, killing germs in food (irradiating), and construction work. Once radiologic material has been used for its purpose, the material remaining is called radiologic waste. Radiologic waste remains radioactive but has no more usefulness. These materials can be found at the following locations:

i Hospitals

i Colleges and universities

i Chemical and industrial sites

i Power plants

Not all radioactive material is tightly guarded, and the waste is often not guarded. This makes use of radioactive material and substances appealing to terrorists.

i Radiologic Dispersal Devices

A radiologic dispersal device (RDD) is any container that is designed to disperse radioactive material. This would generally require the use of a bomb, hence the nickname dirty bomb. A dirty bomb carries the potential to injure victims with not only the radioactive material but also the explosive material used to deliver it. Just the thought of an RDD creates fear in a population, and so the ultimate goal of the terrorist—fear—is accomplished. In reality, however, the destructive capability of a dirty bomb is limited to the explosives that are attached to it. Therefore, if the explosive is sufficient to kill 10 persons without radioactive material, it will also kill 10 persons with the radioactive material added. There may be long-term injuries and illness associated with the use of an RDD, yet not much more than the bomb by itself would create. In short, the dirty bomb is an ineffective WMD in terms of physical damage, but can be psychologically potent in terms of the fear it can create.

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Figure 18 Alpha, beta, and gamma radiation.

Nuclear Energy

Nuclear energy is artificially released by altering (splitting) radioactive atoms. The result is an immense amount of energy that usually takes the form of heat. Nuclear material is used in medicine, weapons, naval vessels, and power plants. Nuclear material gives off all forms of radiation including neutrons (the most deadly type). Like radioactive material, when nuclear material is no longer useful it becomes waste that is still radioactive.

Nuclear Weapons

The destructive energy of a nuclear explosion is unlike any other weapon in the world. That is why nuclear weapons are kept only in secure facilities throughout the world. There are nations that have ties to terrorists and that have actively attempted to build nuclear weapons. However, the ability of these nations to deliver a nuclear weapon, such as a missile or bomb, is, as of yet, incomplete. There is also the deterrent of complete mutual annihilation. Therefore, the likelihood of a nuclear attack is extremely remote.

Unfortunately, due to the collapse of the former Soviet Union, the whereabouts of many small nuclear devices is unknown. These small suitcase-sized nuclear weapons are called special atomic demolition munitions (SADMs). SADM, or “suitcase nuke,” was designed to destroy individual targets, such as important buildings, bridges, tunnels, or large ships. The estimate is that perhaps as many as 80 are missing as of 1998. No other information or updates on the whereabouts of these devices have been made public.

How Radiation Affects the Body

The effects of radiation exposure will vary depending on the amount of radiation that a person receives and the route of entry. There are three levels of radiation exposure:

i Radioactive exposure. Exposure to radioactive material occurred, but the body is not necessarily contaminated.

i External contamination. The skin was contaminated with radioactive material, but the inside of the body is not necessarily contaminated yet.

i Internal contamination. The inside of the body is contaminated.

Radiation can be introduced into the body by all routes of entry as well as through the body (irradiation). The patient can inhale radioactive dust from nuclear fallout or from a dirty bomb, or have radioactive liquid absorbed into the body through the skin. Once in the body, the radiation source will irradiate the person from within rather than from an external source (such as x-ray equipment). Some common signs of acute radiation sickness are nausea, vomiting, and diarrhea. Additional injuries will occur with a nuclear blast such as thermal and blast trauma, trauma from flying objects, and eye injuries.

Words of Wisdom

The inverse square law is derived from physics and describes how radiation travels from its source. If you double your distance from a radiologic source, you will decrease the amount of radiation that you are exposed to by a factor of four. For example: if the radiation dose at 2 feet from the source is 20R, at 4 feet it will decrease to 5R, and at 6 feet away it will be 1.25R. Therefore, the farther away you get from a radioactive source the better, but moving even a small distance away greatly reduces your exposure. Remember that your best allies are time, distance, and shielding.

Medical Management

Being exposed to a radiation source does not make a patient contaminated or radioactive. However, when patients have a radioactive source on their body (such as debris from a dirty bomb), they are contaminated and must be initially cared for by a HazMat responder. Once the patient is decontaminated and there is no threat to you, you may begin treatment with the ABCs and treat the patient for any burns or trauma.

Protective Measures

There are no suits or protective gear designed to completely shield you from radiation. Those people who work in high-risk areas do wear some protection (lead-lined suits); however, this equipment is not available to the paramedic. The best ways to protect yourself from the effects of radiation are to use time and distance, and shield yourself in Level C protection from the source (protection levels are discussed in the chapter, Hazardous Materials).

i Time. Radiation has a cumulative effect on the body. The less time that you are exposed to the source, the less the effects will be. If you realize that the patient is near a radiation source, leave the area immediately.

i Distance. Radiation is limited as to how far it can travel. Depending on the type of radiation, often moving only a few feet is enough to remove you from immediate danger (inverse square law). You should take this into account when you are responding to a nuclear or radiologic incident and make certain that responders are stationed far enough from the incident.

i Shielding. As discussed earlier, the path of all radiation can be stopped by a specific object. It will be impossible for you to recognize the type of radiation being emitted, or even from which direction it is coming. Therefore, you should always assume that you are dealing with the strongest form of radiation and use concrete shielding (such as buildings or walls) between yourself and the incident. The importance of shielding cannot be overemphasized. In one atomic test, a car was parked on the side of a house, opposite the direction of the oncoming blast. The house was completely destroyed, yet the car that was directly next to it sustained almost no damage.

YOU are the Medic   SUMMARY

1. What are some clues that might help you treat your patient?

Pay close attention to the information being provided, not only from those in command but from the general impression of your patient. You know that the toxic substance was released into the air and that its effects are rapid in onset and target multiple body systems. The patient presents in acute respiratory distress, with an altered mental status and a slow pulse rate.

2. Biologic agents can be modified in a laboratory to increase their impact on target populations. What are the primary types of biologic agents that you may encounter during a terrorist attack?

The primary types of biologic agents that you may come into contact with during a terrorist attack include viruses, bacteria, and toxins.

3. On the basis of the information you have, what do you think your patient was exposed to?

The information that you have so far can be indicative of several agents that enter the body through inhalation and have immediate physiologic effects. Potential substances that can present with symptoms similar to those of your patient include phosgene, chlorine, Freon, and cyanide.

4. What should your initial treatment consist of?

As with any patient, initial treatment should focus on identifying and correcting any problems related to airway, breathing, and circulation. The patient’s primary presenting problem is respiratory distress, so oxygen therapy is an appropriate place to start. Because you do not have any information regarding the toxin, specific treatment aimed at reversing its effects cannot be provided.

5. Will the smell of almonds always be present with a cyanide exposure?

This is one of those times when the nose does not always know. Not everyone is able to detect the bitter almond smell associated with the presence of cyanide. Treat the patient based on signs and symptoms until the identity of the substance is known.

6. What is the treatment of choice for a patient with cyanide toxicity?

Several medications act as antidotes, but many services do not carry them. Your response cannot begin until trained personnel wearing the proper PPE remove the patient from the source of exposure, remove the patient’s clothes, and decontaminate any patients who may have been exposed to liquid contamination.

Once those measures have occurred, support the patient’s ABCs, including administering supplementary oxygen, and gain IV access. Severe exposure will require aggressive oxygenation and perhaps ventilation with supplementary oxygen. Always use a bag-mask device or oxygen-powered ventilator device to ventilate a patient exposed to a metabolic agent. The agent can easily be passed on from the patient to you through mouth-to-mouth or mouth-to-mask ventilations. If no antidote is available, initiate transport immediately.

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Prep Kit

i Ready for Review

i As a result of the increase in terrorist activity, it is possible that you could be called to respond to a terrorist event. You must be mentally and physically prepared for this possibility.

i The use of weapons of mass destruction (WMDs) further complicates the management of the terrorist incident. Be aware of your surroundings at all times. The best form of protection from a WMD agent is to avoid contact with the agent. Terrorism is a violent act that is dangerous to human life, in violation of the criminal laws of the United States, to intimidate or coerce a government, the civilian population, or any segment thereof, in furtherance of political or social objectives.

i Terrorists are either international or domestic, and can be categorized as violent religious groups/doomsday cults, extremist political/social groups, technology or cyber terrorists, single-issue terrorist groups, and narcoterrorists.

i The National Terrorism Advisory System (NTAS) replaced the color-coded Homeland Security Advisory System. The NTAS alerts responders to the potential for an attack, provides specifics of the threat if practical, and advises on measures to take for protection. The threat level can be elevated or imminent.

i On the basis of the current threat level, take appropriate actions and precautions. Be aware of established policies that your organization may have regarding the current threat level.

i Indicators that may give you clues as to whether the emergency is the result of an attack include the type of location, type of call, number of patients, patients’ statements, and preincident indicators.

i If you suspect that a terrorist or WMD event has occurred, ensure that the scene is safe. If you have any doubt that it may not be safe, do not enter. Wait for assistance.

i Notification of the dispatcher is essential. Inform dispatch of the nature of the event, any additional resources that may be required, the estimated number of patients, and the upwind route of approach or optimal route of approach.

i Establish a staging area, where other units will converge. Be mindful of access and exit routes.

i Terrorists may set secondary devices to explode after the initial bomb to injure responders and secure media coverage. Constantly assess and reassess the scene for safety.

i A weapon of mass destruction is any weapon or agent designed to bring about mass death, casualties, and/or massive damage to property and infrastructure (bridges, tunnels, airports, and seaports). These can be nuclear, chemical, biologic, and explosive weapons.

i Explosives are the most common weapon used by terrorists. Incendiary weapons involve agents and chemicals used to start fires. Ammonium nitrate bombs and suicide bombers are two weapons commonly used by terrorists.

i Chemical agents include vesicants or blister agents, respiratory or choking agents, nerve agents, metabolic or blood agents, and irritating agents. When a patient has been exposed to one of these, decontamination is a necessary first step. Do not approach the patient until hazardous materials responders have declared that the patient is decontaminated. Treatment will usually include airway management, IV access, and rapid transport.

i Patients exposed to a nerve agent can be treated with an antidote. This is delivered as an auto-injector. Multiple doses may be needed. Follow your local protocols.

i Biologic agents include viruses such as smallpox and those that cause viral hemorrhagic fevers, bacteria such as those that cause anthrax and plague, and neurotoxins such as botulinum toxin and ricin.

i Standard precautions are extremely important when you are treating patients who were potentially exposed to a biologic agent.

i Nuclear or radiologic weapons can create a massive amount of destruction. Radioactive material may be used in a radiologic dispersal device, or dirty bomb, but the majority of the damage from such a bomb is caused by the explosives, not from the radioactive material.

i As with exposure to chemical agents, patients who were potentially exposed to radioactive material must be decontaminated before you have any contact. Time, distance, and shielding are the best ways to protect yourself from radiation exposure.

i Vital Vocabulary

alpha Type of energy that is emitted from a strong radiologic source; it is the least harmful penetrating type of radiation and cannot travel fast or through most objects.

ammonium nitrate A commonly used industrial-grade fertilizer that is not in itself dangerous to handle or transport, but when mixed with fuel and other components, forms an extremely explosive compound.

anthrax A deadly bacteria (Bacillus anthracis) that lies dormant in a spore (protective shell); the germ is released from the spore when exposed to the optimal temperature and moisture. The route of entry is inhalation, cutaneous, or gastrointestinal (from consuming food that contains spores).

apocalyptic violence A type of violence sought by some terrorists, such as violent religious groups and doomsday cults, in which they wish to bring about the end of the world.

asymmetric warfare A type of warfare in which groups wage war with unconventional weapons and covert tactics that are unequal—for example, when there are differences in military resources or capabilities.

bacteria Microorganisms that reproduce by binary fission. These single-cell creatures reproduce rapidly. Some can form spores (encysted variants) when environmental conditions are harsh.

beta Type of energy that is emitted from a strong radiologic source; is slightly more penetrating than alpha, and requires a layer of clothing to stop it.

botulinum A very potent neurotoxin produced by bacteria; when introduced into the body, this neurotoxin affects the nervous system’s ability to function and causes muscle paralysis.

buboes Enlarged lymph nodes (up to the size of tennis balls) that are characteristic of people infected with the bubonic plague.

bubonic plague An epidemic that spread throughout Europe in the Middle Ages, causing over 25 million deaths, also called the Black Death; transmitted by infected fleas and characterized by acute malaise, fever, and the formation of tender, enlarged, inflamed lymph nodes that appear as lesions, called buboes.

chlorine (CL) The first chemical agent ever used in warfare. It has a distinct odor of bleach, and creates a green haze when released as a gas. Initially it produces upper airway irritation and a choking sensation.

communicability The ease with which a disease spreads from one human to another human.

contact hazard A hazardous agent that gives off little or no vapors; the skin is the primary route for this type of chemical to enter the body; also called a skin hazard.

contagious An adjective used to describe the ability of a person infected with a highly communicable disease to pass that disease to another person.

covert Act in which the public safety community generally has no prior knowledge of the time, location, or nature of the attack.

cross-contamination Occurs when a person is contaminated by an agent as a result of coming into contact with another contaminated person.

cyanide Agent that affects the body’s ability to use oxygen. It is a colorless gas that has an odor similar to almonds. The effects begin on the cellular level and are very rapidly seen at the organ system level.

decay A natural process in which a material that is unstable attempts to stabilize itself by changing its structure.

dirty bomb Name given to a bomb that is used as a radiologic dispersal device (RDD).

disease vector An animal that, once infected, spreads a disease to another animal.

dissemination The means with which a terrorist will spread a disease—for example, by poisoning the water supply or aerosolizing the agent into the air or ventilation system of a building.

domestic terrorism Terrorism that is carried out by native citizens against their own country.

DuoDote A nerve agent antidote kit that contains a single injection of both atropine (2 mg) and 2-PAM chloride (pralidoxime chloride) (600 mg).

elevated A threat level in which a terrorist event is suspected, but there is no specific information about its timing or location.

G agents Early nerve agents that were developed by German scientists in the period after WWI and into WWII. There are three such agents: sarin, soman, and tabun.

gamma (x-rays) Type of energy that is emitted from a strong radiologic source that is far faster and stronger than alpha and beta rays. These rays easily penetrate through the human body and require either several inches of lead or concrete to prevent penetration.

guerilla warfare A form of warfare in which a small group that is not part of the official military engages in combat that uses the element of surprise, such as raids and ambushes; sometimes used by terrorists to protect their training camps and bases of operation.

imminent A threat level in which a terrorist event is known to be impending or will occur very soon.

incubation Describes the period of time from a person being exposed to a disease to the time when symptoms begin.

international terrorism Terrorism that is carried out by those not of the host’s country; also known as cross-border terrorism.

ionizing radiation Energy that is emitted in the form of rays, or particles.

LD50 The amount of an agent or substance that will kill 50% of people who are exposed to this level.

lewisite (L) A blistering agent that has a rapid onset of symptoms and produces immediate intense pain and discomfort on contact.

lymphatic system A passive circulatory system that transports a plasma-like liquid called lymph, a thin fluid that bathes the tissues of the body.

lymph nodes Area of the lymphatic system where infection-fighting cells are housed.

MARK 1 A nerve agent antidote kit containing two auto-injector medications, atropine and 2-PAM chloride (pralidoxime chloride); also known as a nerve agent antidote kit (NAAK).

miosis Bilateral pinpoint constricted pupils.

mutagen A substance that mutates, damages, and changes the structures of DNA in the body’s cells.

National Terrorism Advisory System (NTAS) The US system for informing citizens of a potential terrorist threat; replaced the color-coded Homeland Security Advisory System.

nerve agents A class of chemicals called organophosphates; they function by blocking an essential enzyme in the nervous system, which causes the body’s organs to become overstimulated and burn out.

neurotoxins Biologic agents that are the most deadly substances known to humans; they include botulinum toxin and ricin.

neutron radiation Type of energy that is emitted from a strong radiologic source; the fastest moving and most powerful form of radiation; the particles easily penetrate through lead, and require several feet of concrete to stop them.

non-state-supported terrorism Terrorism that is either indigenous or transnational, and that do not receive direction or support from a government.

off-gassing The emitting of an agent after exposure—for example, from a person’s clothes that have been exposed to the agent.

organophosphates A class of chemical found in many insecticides used in agriculture and in the home; nerve agents fall into this class of chemicals.

persistency Term used to describe how long a chemical agent will stay on a surface before it evaporates.

phosgene A pulmonary agent that is a product of combustion, such as might be produced in a fire at a textile factory or house, or from metalwork or burning Freon; a very potent agent that has a delayed onset of symptoms, usually hours.

phosgene oxime (CX) A blistering agent that has a rapid onset of symptoms and produces immediate intense pain and discomfort on contact.

pneumonic plague A lung infection, also known as plague pneumonia, that is the result of inhalation of plague bacteria.

points of distribution (PODs) Strategically placed facilities that have been preestablished for the mass distribution of antibiotics, antidotes, and vaccinations, along with other medications and supplies.

radioactive material Any material that emits radiation.

radiologic dispersal device (RDD) Any container that is designed to disperse radioactive material.

ricin Neurotoxin derived from mash that is left from pressing oil from a castor bean; causes pulmonary edema and respiratory and circulatory failure, leading to death.

route of exposure Manner by which a toxic substance enters the body.

sarin (GB) A nerve agent that is one of the G agents; a highly volatile colorless and odorless liquid that turns from liquid to gas within seconds to minutes at room temperature.

secondary device Additional explosives used by terrorists, which are set to explode after the initial bomb.

smallpox A highly contagious disease; it is most contagious when blisters begin to form.

soman (GD) A nerve agent that is one of the G agents; twice as persistent as sarin and five times as lethal; it has a fruity odor as a result of the type of alcohol used in the agent, and is both a contact and inhalation hazard that can enter the body through skin absorption and through the respiratory tract.

special atomic demolition munitions (SADMs) Small suitcase-sized nuclear weapons that were designed to destroy individual targets, such as important buildings, bridges, tunnels, or large ships.

state-directed terrorism Terrorism directed by a government; the terrorists act as direct agents of the government.

state-sponsored terrorism Terrorism that is funded or supported by nations that hold close ties with terrorist groups, but the terrorist group still acts independently.

suicide bombers People who are terrorists who wear or carry a weapon, such as an explosive, and trigger its detonation, killing themselves in the process to achieve terrorism.

sulfur mustard (H) A vesicant; it is a brownish-yellowish oily substance that is generally considered very persistent; has the distinct smell of garlic or mustard and, when released, it is quickly absorbed into the skin and/or mucous membranes and begins an irreversible process of damaging the cells.

syndromic surveillance The monitoring, usually by local or state health departments, of patients presenting to emergency departments and alternative care facilities, the recording of EMS call volume, and the use of over-the-counter medications.

tabun (GA) A nerve agent that is one of the G agents; is 36 times more persistent than sarin and approximately half as lethal; has a fruity smell and is unique because the components used to manufacture the agent are easy to acquire and the agent is easy to manufacture.

terrorism A violent act dangerous to human life, in violation of the criminal laws of the United States or any segment to intimidate or coerce a government, the civilian population, or any segment thereof, in furtherance of political or social objectives.

V agent (VX) One of the G agents; it is a clear, oily agent that has no odor and looks like baby oil; over 100 times more lethal than sarin and is extremely persistent.

vapor hazard An agent that enters the body through the respiratory tract.

vesicants Blister agents; the primary route of entry is through the skin.

viral hemorrhagic fevers (VHFs) A group of diseases that include the Ebola, Rift Valley, and yellow fever viruses, among others. This group of viruses causes the blood in the body to seep out from the tissues and blood vessels.

viruses Germs that require a living host to multiply and survive.

volatility Term used to describe how long a chemical agent will stay on a surface before it evaporates.

weapon of mass destruction (WMD) Any agent designed to bring about mass death, casualties, and/or massive damage to property and infrastructure (bridges, tunnels, airports, and seaports).

weaponization The creation of a weapon from a biologic agent generally found in nature and that causes disease; the agent is cultivated, synthesized, and/or mutated to maximize the target population’s exposure to the germ.

Assessment in Action

Your city will be hosting the Super Bowl next year. As part of the preparation, the local hospitals are hosting a continuing education seminar on the emergency treatment of patients during an act of terrorism.

1. Which type of radiation cannot travel fast or through most objects?

A. Delta

B. Gamma

C. Alpha

D. Beta

2.____affects the nervous system’s ability to function and causes muscle paralysis.

A. Tabun

B. Botulinum

C. Ricin

D. Sarin

3. Ebola is an example of a:

A. plague.

B. neurotoxin.

C. mutagen.

D. viral hemorrhagic fever.

4. What was the first chemical agent ever used in warfare?

A. Chlorine

B. Phosgene

C. Mustard gas

D. Cyanide

5. The routes of entry for anthrax include:

A. inhalation.

B. cutaneous.

C. gastrointestinal.

D. All of the above

6. The most deadly substances known to humans are:

A. pulmonary agents.

B. neurotoxins.

C. organophosphates.

D. vesicants.

7. Some toxins can be derived from certain plants and flowers. Which of the following toxins is made from the castor bean?

A. Sarin

B. Ricin

C. Mustard gas

D. Phosgene

8. An example of a disease that infects the lymphatic system is:

A. botulism.

B. Rift Valley fever.

C. bubonic plague.

D. anthrax.

9. Potential sources of radiologic waste include:

A. hospitals.

B. universities.

C. power plants.

D. All of the above

10. Strategically placed facilities that have been preestablished for the mass distribution of antibiotics, antidotes, vaccinations, and other medications and supplies are called:

A. strategic warehouses.

B. points of distribution.

C. rapid deployment units.

D. central response centers.

Additional Question

11. What are some of the challenges that will be faced if medical resources become scarce?