“Terrorism is the use of violence, threats, intimidation or information manipulation for revenge, politics, support of a cause of furthering of a criminal enterprise.” (Christen & Maniscalco, 2002c, p. 16)
The bombing of the World Trade Center in 1993 was a use of violence that brought terrorism home to United States shores. Terrorists attacked the World Trade Center because it symbolized American prominence and wealth. The bombing of the Alfred P. Murrah Federal Building in the City of Oklahoma City on April 24, 1995 expanded our experience with large loss of life and the massive grief caused by the acts of terrorism. Oklahoma City also made us aware that our own citizens were highly capable of actually bringing about large destruction and loss of life. Retrospectively the World Trade Center bombing of 1993 seems minor compared to Oklahoma City and the World Trade Center Attack of September 11, 2001.These events provided EMS with formidable safety and patient triage challenges and experience.
Terrorism brings a factor of intentional harm as means of focusing attention for ideology or revenge for an incident. For example, the FBI’s handling of Waco hostages was the impetus for the bombing of the Murrah federal Building in Oklahoma City. The deliberate aspect of terrorism combined with a terrorist’s intention of killing, not only civilians but also rescuers and public safety personnel, heightens the stakes for all public safety personnel when responding to incidents from terrorism.
There are several types of weapons that terrorist may use. Biological, nuclear, incendiary, chemical and etiological types of weapons may be used against the public and responders. The use of hi-jacked 757s on September 11, 2001 demonstrated the high lethality of terrorism with basic tools and conventional technology. The prospect of terrorist use of weapons of mass destruction on American interests once again expands the range of possibilities of what EMS personnel may be called upon to respond and the safety challenges presented to EMS providers. “The primary objective of a terrorist/tactical violence incident is to create sympathy support for an ideology. The death and mayhem demonstrate a case or help the purpose of the perpetrators accomplish an immediate goal. For this reason, EMS operations are central objectives of the first response force”. (Christen & Maniscalco, 2002c, p.21).
Christen & Maniscalco, in Responding to the Terrorist Incident (2000, p. 2) said when responding to a terrorist incident, “initial responders are confronted with an unfamiliar, unpredictable and unsafe scene. The terrorist scene confronts rescuers with challenges in safety, patients care and scene management.” The consequences of terrorism range form personal injury, rescuer injuries and fatalities and the prospect of weapons of mass destruction (WOMD). EMS providers and educators need to combine our best information and practices on safety, triage, and scene management.
EMS Response to Terrorist Mass Casualty Incident
EMS response to a MCI and suspected terrorist incident requires personnel to actively consider safety factors, observe the scene for possible hazards or attackers and be efficient in treatment of injured or ill patients. “In most emergency response agencies the survival skills for living through a terrorist/tactical violence incident require development and training. The most important factor is daily use of IMS.” (Christen & Maniscalco, 2002a p.56) A terrorist event is different from MCIs because of the danger involved. “For emergency responders, this raises two important considerations. First, they are being called upon to respond to an increasing number of terrorist-related incidents…Second, emergency services personnel in fire, EMS and law enforcement must seriously consider the fact that they themselves may well be the targets of terrorist aggression.” (Sachs, 2003).
Scene safety must be continual and dynamic to detect evolving threats and scene challenges to rescuers. “Whether a Haz Mat response is from industrial incidents, accidents of WOMD the response of fire departments, police departments and EMS are required. EMS personnel must be ready for a Haz Mat. Pre-plans, experience in medical monitoring, decontamination and patients care. (Strieger, 1999, p.64) In a Haz Mat response, “the objective is to first decontaminate salvageable patients that are in immediate need of medical care.” (Christen & Maniscalco, 2002c, p. 240).
An interesting comparison to the American standard of decontamination of decontamination first, then treat and transport is the Israeli view that contaminated patients can be transported in a ventilated ambulance. The Israeli’s feel that decontamination is not possible because a WOMD incident cannot be controlled. (Gilmore, 2000, p. F-13) In St. Luke’s Hospital in Tokyo of the 640 patients that arrived following the subway Sarin attack, 64 patients arrived by ambulance. 90% of the patients arriving at St. Luke’s came by means other than EMS and with no decontamination.
Because of the large number of patients that may be affected, “performance of accurate triage must be an essential skill for those responding to terrorist attacks in which there are multiply injured victims.” (Yesky, 1996, p.64) EMS is responsible for identifying and transporting the “Immediate patients to hospitals which can handle these patients. For this reason, triage, decisions of need versus resource is critical at a terrorist incident.
Responses to terrorist incidents present a complex and evolving scene for rescuers. Literature on EMS response to terrorism shows that the initial actions of responders are critical in setting up effective operations and ensuring safety. Responder must be able to recognize the outward signs of a terrorist attack and know how to maintain safety. When dealing with a terrorist related MCI EMTs and paramedics must be able to effectively use triage to ensure that resource such as supplies, ambulances and specialty medical care are available to those who benefit the most from the treatment. The ability to recognize these events and institute appropriate actions is paramount to survival of EMT and paramedics as well as the patients. These factors affecting EMS response to a terrorist related MCI were considered when constructing the survey and reviewing actual terrorist incidents.
Evidence-Based Lessons Learned from MCIs
April 19, 1995. Oklahoma City Bombing, Murrah Federal Building.
This bombing was significant because it was a domestic terrorist incident, which injured and killed a relatively large number of patients. #zz were killed, 444 patients were treated for physical injuries. 354 patients were treated and released from hospitals. 90 of the patients (20%) were admitted to the hospital..(make table for patients). # went by foot or private means. From an EMS MCI management standpoint this incident was important because of the number of casualties treated, the unique safety problems and length of the operation. “EMS providers were completely unprepared for what they saw.” (Nordberg, 1995, p.50) “Responders to the bombing were faced with large groups of patients and people covered in other peoples blood. Patients had been seriously injured from the explosion or injured from flying glass.” (Nordberg, 1995, p.50)
The magnitude of the City of Oklahoma bombing unfolded as the City of Oklahoma Fire Department organized their response and rescue efforts. “Accountability is critical in mass casualty incidents- not also for personal safety also for effectiveness in patient treatment.” (City Of Oklahoma, 1996, p.48). Control of this event and its perimeters was difficult until a recall was made removing all personnel from the building because of a bomb. This withdrawal of personnel allowed OKC FD to establish perimeter control and accountability of personnel on the scene. “Instead of setting up perimeter control and letting EMS and fire personnel handle the rescue operations, the police officers got involved in carrying victims out of the building. As a result, we ended up with a lot of chaos and people into the scene who didn’t belong there.” (Nordberg, 1995, p.64)
“Maintaining control of the manpower pool important, although in the earliest stages of the incident extremely difficult: Civilians tended to remain in staging for only about 10 minutes before there desire to help compelled them to the Murrah Building.” (Davis, 1995, p.9)zz check page # or 2nd source? “One of the problems we faced before the bomb threat was unaccountability for the many civilian medical personnel who had come to the scene in response to media requests and were not following ICS.” (Davis, 1995, p.102). “Unfortunately, the desire to help ended in tragedy for one nurse, who entered the building and was killed by falling debris.” (Nordberg, 1995, p.63) “One problem was that the hospital response team members didn’t know the triage colors or how to operate under the incident command system.” (Shannon, 1995) Effective perimeter control was established after the bomb scare.” (Davis, 1995, p. 102) Accountability is critical in mass casualty incidents-not 0nly for personnel safety, but also for effective patient care. (Davis, 1995, p.102)
This incident also presented enormous BBP hazards as hundreds of bodies were removed from the debris. Experience at OKC demonstrated “Always begin your health and safety protocols at the highest appropriate safety level and de-escalate as it is determined safe o do so (City of Oklahoma City, 1996). EMS operations are paramount to this operation. EMS treated treated. “EMS operations included “The EMS branch of the OKCFD is comprised of 4 main groups, triage, treatment transport and decontamination (City of Oklahoma City, 1996, p. 146). Triage operations were set up at locations where large amounts of patients were gathering.
“Oklahoma City Hospitals were overwhelmed with patients brought in by private means, EMS could not assess how many patients each hospital had.“ (City of Oklahoma City, 1996, p. 147).
“We could not communicate with hospitals, we dispatched police to individual hospitals to obtain available patient capacity counts.” (Davis, 1995, p.99) “Many victims were transported to health-care facilities by private vehicles: some even walked.” (Davis, 1995 p. 100)
EMS personnel in OKC were trained each year for a minimum number of hours in MCI management. “The importance that a minimum # of hours be incorporated into all training programs on a yearly basis.” (City of Oklahoma City, 1996, p.251).
FEMA task force experience demonstrated the need to educate members responding to MCIs in the signs and symptoms of stress (City of Oklahoma City, 1996, p. 309)
Experience from Oklahoma City concerning training showed the importance of safety, accountability, even patient distribution to hospitals and training together. “Develop a disaster plan and practice it regularly. All agencies that will be involved in the incident-including hospitals and their emergency departments and all area emergency medical services, fire departments and law enforcement agencies-should participate in the training. (Davis, 1995, p.103)
1995 Tokyo Subway Sarin Attack.
“On March 20, 1995 a terrorist attack by a religiously motivated cult resulted in the release of a toxic gaseous substance in five subway cars on three subway lines.” (Okumura, 1996, p. zz) During this attack, which was conducted at the height of rush hour, chemical releases were timed to occur at a subway convergence point under the Japanese national government’s ministry offices. Japanese officials discovered that the gaseous fumes were a derivative of sarin gas. Sarin is a potent organophosphate poison. “As a result of the attack, 11 commuters were killed and 5,000 persons required emergency medical evaluation.” (Okamura, 1996, p. zz) among the 640 patients who presented at St. Luke’s Hospital on the day of the sarin attack, 64 patients arrived at the ED by the ambulance and 35 arrived in minivans belonging to the Fire Defense Agency. The remaining 541 victims arrived with assistance from non-medical trained motorists. (Okamura, 1996, p. zz) “The Tokyo attack was the largest documented exposure of a civilian population by a warfare nerve gas. “
1999. Seattle Bus Accident.
In this incident a person held people on the bus hostage and shot the driver in the head. The bus careened over a bridge landing 60 feet below. This incident poses problems with access, patient location and triage. Crews on the scene had difficulty forming a triage area because patients were spread out. Patients were transported with diesel on them, not deconned before transport FD had to got to the ED and decontaminate the patients.” (Heightman, 1996, p. 94). Triage problems arose from the distance between the patients and the severity of patients. “START is a very effective protocol under normal MCI procedures. But in this incident the patients were spread out by over 50 feet.” (Heightman, 1999, p. 92) In this response police officers were placed in the treatment area and in ambulances because the perpetrator could not be identified.” (Heightman, 1996, p. 93)
World Trade Center Attack, September 11, 2001
As a result of the World Trade Center Attack, hazards ranging from massive debris piles containing patients and bodies which were unstable to all types of materials which were burning presenting unknown health hazards. The unpredictable nature of this incident was accentuated when 7 World Trade center fell to the ground in a brief moment. 7 World Trade center was a 47-story building, which fell from its height in a matter of seconds. These events left rescuers feeling very tentative about the very ground they stand on and the buildings they must enter. In chaotic times such as these rescuers depend on their training and coworkers.
The World Trade Center collapse encompassed 16 acres of land and 7 buildings. There was no perimeter control of the World Trade center site for the first few days. (interview with Jay Swithers USAR, NYTF-1) Medical personnel responded to the site to help patients. Health care workers, faced with no patients to care for started to help move debris. Many people, meaning well, entered the collapse sight with inappropriate clothing and no protective equipment. During the collapse of the north and south tower 10 EMTs and paramedics were killed. Many EMS personnel were seriously injured. The world trade center attack represents the greatest loss of rescue personnel in history due to a terrorist attack.
The RAND group brought together responders from OKC, Tokyo and New York City to discuss problems unique to terrorist incidents. The conference, Protecting Emergency Responders, Lessons Learned from the Attack, gathered experiences and recommendations for change. “The discussions at the conference identified 2 fundamental safety issues. Issues from the RAND conference concerned hazard assessment and information regarding PPE use. This conference identified there was a lack of information about hazards and equipment, as well as inadequate management and communication of information. (Jackson, Peterson, Bartis, 2002, p. ).
Concerning training problems at the World Trade Center. “Responders had training but were left wondering what the book said because they did not take the training seriously because they didn’t feel these events were something they would see.” (Jackson, Peterson, Bartis, 2002, p.41) RAND and also identified that, “Those EMS groups with FD affiliation usually had some knowledge about hazards and rescue requirements. But many did not have access to the equipment they needed.” (Jackson, Peterson, Bartis, 2002, p.20)
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