EMS Response to Terrorism

"I think about the job done yesterday, and tip my hat to the responders, pray for the victims, and thank whatever forces led me to this calling." -Michael Morse, rescue captain with the Providence Fire Department

Terrorism● “The unlawful use of force or violence against persons or

property to intimidate or coerce a government, the civilian population or any segments thereof, in furtherance of political or social objectives"

● Typeso Domestic - activities are directed at a government or

population, without foreign direction Environmental terrorists, Survivalists, Militias, Racial-hate groups,

Extreme political or religious groups

o International -"activities are foreign-based and/or directed by countries or groups outside the target country or whose activities cross national borders.”

First Responders Role● EMS is usually principle target of terrorist attacks

o keep safety top priority!

● Isolationo Incident command and law enforcement's job is to isolate

hazards and organize evacuation

● Notification- potential crime scene o follow protocols, incident communications may request

additional specialized agencies

● Identification of threat (containers, or specific indicators)

● protect critical assets!

● Gross decontamination (do it)

First Responder Role Count. ● Scene Size-up

o signs of HAZMATo Unconsciouso SLUDGEM signs (explained later)o skin irritants and symptomso difficulty breathing

● Situational Awarenesso mass casualties/fatalities with little or no traumao responder casualtieso dead animals and plants

● Don't Rush In! (clear scene, PPE, secondary explosive devices, search all patients)

Identify Threat Posed by Event - OTTO

● potential act of terrorism is crime scene● OTTO

o Occupancy (location) - Symbolic targets, public/assembly areas, businesses, infrastructure

o Type of event -scene involves guns, explosions, mass casualty with no trauma

o Timing of event - holidays, anniversary, public gatherings, busy times of day

o On-scene warning signs -unexplained patterns, signs, symptoms, and containers

Take Home Message is you remember nothing else

● Time/Distance/Shieldingo Time - minimize exposure, perform quicklyo Distance - maximize, distances given in Emergency

Response Guidebooko Shielding - Emergency Response Guidebook for

specific shielding, appropriate PPE, breathing gear, hide behind cars, buildings, wear HAZMAT suits, get vaccinations

Weapons of Mass Destruction

● CBRNEo Chemicalo Biologicalo Radiologicalo Nuclearo Explosiveo Criminal activities

● Harms Posed by Threat TRACEM-Po Thermalo Radiologicalo Asphyxiationo Chemicalo Etiological (disease)o Mechanical o Psychological

Chemical Incidents ● TRACEM-P● usually exposed

through inhalationo heat, explosives, and

sprayers can aerosolize materials

o could be ingestion, injection, absorption

● Self-Protectiono respiratory gear

HAZMAT clothingo decontaminate pts

● Volatility - choose chemicals w/ low boiling point and high vapor pressure to evaporate quicklyo greater airborne

release potential● Agents can be

gaseous, liquid, or solid

Classes of Chemical Agents

● Choking agentso e.g. chlorineo causes - upper or lower-respiratory

irritation, lacrimation, chest pain, dyspnea, coughing, laryngeal edema, pulmonary damage/ edema

● Cyanides o Prevent use of oxygen in cellso highly volatile, rapidly acting

chemical agents.o e.g. hydrogen cyanide (AC)o cause - air hunger, hyperpnea,

apnea, seizures, coma, and death

● Vesicating (blister) agentso e.g. mustard gas, sulfur

mustard (HD), nitrogen mustard (HN), agent T

o may be toxic to the lungs, eyes, and mucous membranes

o lesions are usually skin, but can be respiratory, ocular, and GI

o can also cause - cough, bloody sputum, and dyspnea

o symptoms may not occur for several hours

Classes of Chemical Agents Count.

● Nerve agentso Inhibit neurotransmissiono signs- SLUDGEM!

Salivation Lacrimation Urination Defecation GI Upset Emesis (vomit) Miosis (small pupils)

o can also cause airway problems

o Onset varies from 1 minute to a few hours (skin vs air)

● lacrimators / irritating agentso e.g. (tear gases)o cause - nasal/ocular discharge,

photophobia, burning sensationso may cause -chest tightness tightness,

shortness of breath, and malaise

● Incapacitating agentso delayed-onset (1-4 h)o cause tachycardia, dizziness, vomiting,

blurred vision, stupor, confusion, and random activity

o can make person docile, belligerent, stuporous, or confused (seem intoxicated)

Biological Incidents● Caused by

o bacteria, viruses, and/or toxins

● focused emergency or public health emergency?

● Role of EMS is primarily supportiveo material can replicate

itself

● Four major routeso absorption, ingestion,

injection, inhalation

● Exposed or Contaminated?

● TRACEM● Self-Protection

o PPE, respiratory protectiono Get as much info as

possible and prioritize

Examples of Biological Weapons

Anthrax (Bacillus anthracis) easy to access, and durable, small number of anthrax spores causes the inhalational form● 1- to 3-day incubation period, hard to

diagnose in early stages and difficult to treat once clinical signs are apparent

● signs/ symptomso necrotic lesions that spontaneously

healo fevero dyspnea (shortness of breath)o necrotizing hemorrhagic mediastinitis

(bloody death of tissue)o hypotension

● Death within 24-36 hours up to 7 days● Vaccine available

Brucellosis (Brucella) bacteria less commonly fatal● signs/ symptoms

o draining lesionso fevero malaiseo osteomyelitis (bone

infection)o genitourinary (genital and

urinary) infectionso endocarditis (inner heart

lining inflammation) - cause of death

Examples of Biological Weapons Count.

Encephalitis viruses mosquitoes are a vector● Signs and Symptoms

o fevero headacheo confusion and

obtundation (dulled senses)

o dysphasia (impaired speech)

o seizures and paresis● vaccine for Venezuelan

equine encephalitis (VEE) is available

Smallpox virus vaccine no longer is produced● Aerosol exposure signs and symptoms

o viremia (viruses in blood)o malaiseo fevero headache and/or deliriumo prolonged rash

Allergens mite/insect particles, epithelium, hair, urine, feces, and powdered enzymes● could cause respiratory symptoms,

conjunctivitis (pink eye), and/or dermatitis (skin inflamation)

Others● Clostridium botulinum● Yersinia pestis (plague)● Rift valley fever

Radiological

● Effects of radiation on bone, GI, CNS

● TRACEM-P● Self-Protection

o Time, distance, shielding

o Radiologic detecting equipment,

● assume dissemination

● radiological dispersiono practical and difficult to

detect o symptoms are delayedo treatable if early detection

● Deviceso Military nuclear deviceo Improvised o Radiological dispersal

device (dirty bomb)o Sabotage

Incendiary

● variety of deviceso may involve attacks

on a fixed target or group of people

o assume designed to disperse bio, chem, radiologic materials

● TRACEM-P● Self-Protection

o preblast vs postblast

● Blast injury patternso Lung injury - bradycardia,

apnea, and hypotensiono Ear injury - tympanic

membrane (loss of hearing, blood, ringing)

o Abdominal injuryo Brain injury - concussion

or mild traumatic brain injury (MTBI)

Boston Marathon Bombings

● responders performed selfless and heroic acts of care and compassion, situation was special due to large amount of EMS who were on hand for the marathon itself and were on the scene within seconds, race tents were utilized as cold zone o Doctors were "pulling ball bearings out of people in the emergency room...a

terrifying scene of shattered glass, bloodstained pavements and severed limbs." -terrorism expert

o "Somebody's leg flew by my head. I gave my belt to stop the blood" -John Ross

o "They just started bringing people in with no limbs" -Tim Daveyo "They just kept filling up with more and more casualties...Most everybody was

conscious.They were very dazed." -Lisa Daveyo "This is something I've never seen in my 25 years here ... this amount of

carnage in the civilian population." -Alisdair Conn, chief of emergency services at Massachusetts General Hospital

CNN Report on First Responders

We Can't Always Help● unexploded bombs were rampant Adrian judged scene

was not secure

● The conflict between personal priorities and the call to duty can be significanto sometimes we can become part of the problem not aid solution

● "They were disoriented and dehydrated from the race, and really couldn't talk much...I couldn't do very much for them, other than stay with them until friends arrived to help them home." o -EMT Adrian Will-Orrego, junior at Northeastern

Adam Lane● We had just left the area a minute before the explosion...We could feel the

concussive energy of the primary blast wave

● At first we didn't know what it was...We saw a lot of people run by. It seemed that it was almost instantaneous that medical responders were all over the place, tending to the wounded

● I made the right decision to stay with my friends and go help other runners who were not injured but were still shocked and exhausted by what happened

● You realize after something like this, there is a lot that is just beyond your control...Had we been delayed a few minutes, things could had been very differento -Adam Lane EMT, PA student studying at the Massachusetts College of

Pharmacy and Health Sciences

Marathon: IEDs● Improvised

Explosive Device: o “homemade” bomb or

destructive device created to destroy, incapacitate, harass, or distract

● wide variety of forms

● can be thrown, placed, or concealed

composed of● package

o e.g. vehicle, a package, cans, backpacks, vests etc.

● initiating system o set off the main charge to make it

detonate o e.g. cell phone, toy RC, etc.

● main charge o almost always includes a blasting cap

and batterieso any type of battery can be used (e.g. 9-

volt, AA, car batteries, etc.)

IED Deployment Triggered● Over time: allow enemy to

escape or to target victims● On command: choose the

optimal moment, used against mobile targets with established patterno include wires or radio

controlled devices● Victim

o switches include pull or trip, pressure, pressure release, movement-sensitive, light-sensitive, proximity

Deployment Techniques● disguised in a variety of things ● Multiple IEDs can be linked together with

detonation cord o charges detonate simultaneously

● often secondary devices and multiple explosions to increase victimso scene safety!

● gunfire, small bombs, and other distraction tactics can bait victims into the kill zone of a second IED

● Multiple locations are common with IED bombers so command officers must be mindful of their resources

Specific IEDs● VBIED: parked vehicle in a high traffic area

● VBIEDS: suicide driver VBIEDo hard to detect and stopo bomber -mobile, able to choose time, place, and victims

● Suicide Bombers Personal Borne IEDS (PBIED) attack with an explosive vest, belt, or baggage attached to persono commonly hold up to 12 lbs of explosives (can be as high as 45) and

incorporate fragment materials into the designo potential attack

attempting to circumvent security checkpoint or gate wearing too much clothing for the weather suspicious bulges in clothing

Works Cited EMS1 Staff. “3 dead, dozens injured after Boston Marathon explosions.” EMS1. N.p., 15 Apr. 2013.

Web. 19 Apr. 2013. <http://www.ems1.com/mass-casualty-incidents-mci/articles/1432242-2-dead-

dozens-injured-after-Boston-Marathon-explosions/>.

French, Glenn. “Boston bombings: IED recognition for patrol officers.” PoliceOne. N.p., 17 Apr. 2013.

Web. 19 Apr. 2013. <http://www.policeone.com/terrorism/articles/6199597-Boston-bombings-IED-

recognition-for-patrol-officers/>.

Hsieh, Art. “Boston bombings: EMT stories from the scene.” EMT1. N.p., 18 Apr. 2013. Web. 19 Apr.

2013. <http://www.ems1.com/columnists/art-hsieh/articles/1434117-Boston-bombings-EMT-stories-from-

the-scene/>.

Works Cited Count.Kaye, Randi. CNN News Report. Youtube. N.p., 17 Apr. 2013. Web. 21 Apr. 2013.

<http://www.youtube.com/watch?v=fRD90hRb5gQ>.

Limmer, Daniel, et al. "EMS Responce to Terrorism." Emergency Care. Ed. Edward T.

Dickinson. 12th ed. Upper Saddle River: Pearson Education, 2012. 1063-97. Print.

Morse, Michael. “The Boston bombings: EMS efforts made me proud, humble.” EMT1. N.p., 16

Apr. 2013. Web. 19 Apr. 2013.

<http://www.ems1.com/columnists/michael-morse/articles/1432737-The-Boston-bombings-

EMS-efforts-made-me-proud-humble/>.

Stephens, Everett. “EMS and Terrorism.” Medscape. N.p., 24 July 2008. Web. 19 Apr. 2013.

<http://emedicine.medscape.com/article/765132-overview#showall>.