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                                  Biological & Chemical Terrorism   
                           and the Medical Preparedness Paradigm 
                               A Protective Research Group Perspective 
                                                November 1, 2000 
                                                    Prepared by 
                                              Wade M. Knapp, CPS 
                                            Lee A. Knapp, RN, CEN 
                This document should not be considered a definitive study of biological and chemical 
                  Terrorism or the medical response necessities required for such acts of terrorism. 
 The threat of terrorism involving biological and chemical Weapons of Mass Destruction is a public safety issue 
that has received great attention in the United States.  Not since our society was confronted by the possibility of 
nuclear attack during the Cold War era has an issue been of such public and political importance.  Originally 
designed for use as a combat weapon in the theater of war, biological and chemical weapons were eventually 
considered inhumane and discontinued.  The United Nations Biological and Chemical Conventions banned the use 
of these weapons; however, not all nations have agreed with or signed these Convention documents. 
It is suspected that several rogue nations, and numerous international and domestic terrorist groups, may possess 
these weapons, possess the equipment and components necessary to manufacture these weapons, or possess the 
desire to obtain or develop these weapons. Information regarding this threat is both extensive and being released to 
the general public at an alarming rate.  Analysis being released by U.S. Government Agencies, U.S. Military, 
Research Organizations and a host of other professionals indicates that the threat of a terrorist act utilizing one of 
these Weapons of Mass Destruction is both real and credible.  This analysis often states that it's not a question of 
if such an attack will occur, but when and where such an attack will occur.  
 Medical professionals will play a vital role in a disaster stemming from the intentional use of a Biological or 
Chemical warfare agent. Biological and chemical agents used as weapons have the potential of creating 
unbelievable numbers of medical casualties.  Injured victims will have to be transported to hospitals in order to 
receive proper medical treatment.   Hospitals must be prepared and equipped to receive and treat the victims of 
such a terrorist incident.  By and large, U.S. hospitals are still unprepared to respond to terrorism incidents of this 
type.  The medical community themselves must realize this and begin to take steps to effectively manage medical 
disasters resulting from the use of biological and chemical Weapons.  


                                  The Weapons of Mass Destruction Threat 
 What is a Weapon of Mass Destruction?  Weapons of Mass Destruction (WMD) are specifically designed to 
result in the death or injury to large numbers of people at one time.  These weapons fall into four basic categories: 
Nuclear Weapons, Biological Weapons, Chemical Weapons, (which together make up the NBC weapons triad) and 
Large Conventional or Improvised Bombs as the newest, and last, category.  It is important to understand both the 
destructive nature of these weapons and the potential threat they pose to not only our society, but the global 
community as well.  These weapons, if in the wrong hands and properly used, have the ability to bring about the 
deaths of countless numbers of human beings in a very short time.  The reality of this makes these weapons the 
most hideous ever devised by mankind.  The following text will provide a brief summary of these weapons and 
the threat they pose. 
 Nuclear Weapons 
 Nuclear Weapons (NW) pose the greatest threat of potential death and destruction within our society.  This threat 
paradigm is both old and new depending upon how you view it. Nuclear weapons are the newest of the NBC 
triad, but the one most commonly known.  This is due to the extensive Nuclear Warfare preparedness the United 
States has undergone from the 1950's to present day.  Nuclear weapons possess enormous potential for loss of 
life and destruction of property.  Measured in megatons (1 megaton is the explosive force equal to 1 million tons 
of TNT), these weapons produce a blast effect, which is intense enough to consume everything in its path for 
miles beyond the point of detonation.  In addition to the sheer explosive force of these weapons, they also produce 
a radiological effect that is termed fallout.  Fallout occurs as a result of the nuclear detonation that produces 
radioactive dust particles.  These radioactive particles can be carried by the wind, contaminating people and the 
environment for miles beyond the areas affected by the weapon's explosion.   
 In the past, the primary threat of nuclear attack resided with the few global superpowers possessing the 
technology to do so, including the United States, Soviet Union, and China.  Today, with the advances in nuclear 
energy technologies, many nations around the globe now possess these weapons or possess the fundamental 
equipment and knowledge necessary to design and build these weapons.  This reality makes the modern day threat 
of nuclear weapon attack by a foreign nation an even greater concern.  However, the potential for use of a 
Nuclear weapon by terrorists is limited due to several factors.  Nuclear weapons and the raw materials used to 
make these weapons are strictly regulated on a global wide basis.  They are extremely difficult and expensive to 
make or acquire and easily detectable by governments using sophisticated radiological monitoring devices.  This is 
not to say that such a threat does not exist or should not be considered.  Theoretically, a terrorist with adequate 
resources could obtain or manufacture such a weapon, and one should assume that there are terrorist groups with 
just such an interest.  To date, an incident of terrorism involving the detonation of a nuclear weapon has not 
 Biological Weapons 
 Biological Weapons (BW) involve the use of microorganisms (bacteria, viruses, and fungi) or toxins (poisons 
from living organisms) to produce death or disease in humans, animals, and plants.  Biological Weapons are the 
oldest of the nuclear, biological, chemical (NBC) triad and have been used by governments in warfare for 2,500 
years.  These biological agents are more deadly on a compound per weight basis than chemical agents and rival 
nuclear weapons in killing potential.  Botulinum toxin, for example, a neurotoxin produced by the Clostridium 
botulinum bacteria, is approximately 15,000 times more toxic than the nerve agent VX and 100,000 times more 


toxic than the nerve agent sarin.  The biological agents of most concern include Anthrax, Smallpox, and Plague, 
but many other agents are also classified as potential weapons.  There is a growing concern that through genetic 
manipulation, these agents could be refined and made more powerful, as well as resistant to standard medical 
 In 1984, members of the Rajneesh Cult, a religious extremist group, used salmonella bacteria to contaminate food 
items on salad bars in ten restaurants located in the City of Dalles, Oregon.  The purpose of this act was to cause 
illness among townspeople in the hopes of influencing a local election.  This act resulted in 750 individuals 
developing salmonellas, of which 60 where hospitalized.  All individuals recovered from the illness.  Several group 
members were arrested and later convicted of the crime.  During the criminal investigation, it was reported that 
the group had been experimenting with attempts to aerosolize HIV contaminated blood.     
 During the 1991 Persian Gulf War, the threat of biological warfare against American soldiers increased the public 
awareness of the possibility of a potential biological attack against U.S. cities.  The reality of this threat gained 
credence in 1996 when two high ranking Iraqi military officials revealed that during the war, Iraq had produced 
and was prepared to use 19,000 liters of botulinum toxin and 8,500 liters of anthrax. 
 Biological weapons pose as great a threat as nuclear weapons and their potential for use by terrorist groups is 
thought to be feasible. However, unlike nuclear weapons that have the ability to destroy property, biological 
weapons are only a risk to people and livestock.  The majority of these biological organisms is available in nature 
and requires only minimal scientific knowledge and equipment to produce them as weapons. Rogue nations and 
terrorist organizations have shown a strong interest in the use of biological weapons because these weapons are 
inexpensive to produce, difficult to monitor and can produce illness and death in large numbers.  Called the "poor 
man's nuclear bomb", biological weapons can be produced with minimal startup equipment and supplies and can 
be introduced easily into areas with large groups of people. Several nations and many foreign and domestic 
terrorist groups are suspected of possessing biological weapons, or the equipment and components necessary to 
manufacture such agents.  These agents are appealing to countries or terrorist groups with limited resources due 
to the fact they are relatively simple to manufacture.  Additionally, biological agents have been utilized as terrorist 
weapons in the past, making this a threat that should not, and cannot, be overlooked. 
 Chemical Weapons 
 Chemical Weapons (CW) are the second oldest in the NBC triad. Chemicals were first used as offensive warfare 
agents during World War I.  In 1915, Germany released 168 tons of chlorine onto troops at Ypres, Belgium.  In 
1917, sulfur mustard was used by German troops again at Ypres, Belgium.  The first chlorine attack represented 
merely an escalation of the existing use of chemicals as irritants.  The use of irritating smoke, such as the burning 
of sulfur, dates back to antiquity.  During World War II, the German military refined industrial chemicals into 
extremely lethal compounds. It was later discovered that these compounds were used to kill prisoners held in 
concentration camps.  These early chemical compounds would become the foundation for what is now referred 
to as Nerve Agents.  
 In March of 1995, the Aum Shinrikyo cult, a religious extremist group, perpetrated a terrorist attack in the 
subway system in Tokyo, Japan.  The weapon used was the chemical nerve agent, sarin.  This attack resulted in 
the deaths of 12 individuals, approximately 1000 individuals were moderately to severely injured, and over 5000 
individuals affected.  Several members of the cult were subsequently arrested and later convicted of the crime.  
The post event investigation revealed that the sarin agent used in the incident was only 25% the purity of standard 
weapons grade nerve agent and was disseminated using a very crude method.  This raises the question, what 



would the outcome of this incident have been if the agent used was of pure weapons grade and disseminated more 
 Chemical weapons are classified as Nerve Agents, Pulmonary Agents, Vesicants, Blood Agents, and Riot Control 
Agents. Chemical agents can be in the form of solids, powders, liquids or gases. Various agents can be irritating, 
incapacitating, injurious or deadly.  Some agents cause only local effects, some have only systemic effects, while 
others have both effects.  Agents may be inhaled, swallowed, or enter the body through eyes or skin.  The effects 
can be immediate or delayed. 
 Since chemicals are readily available or easily made, of low cost, are easily transportable, and can be delivered by 
various routes, chemicals make an excellent weapon for the terrorist.  Most countries, including the United States, 
are not prepared to deal with a strategic terrorist attack using chemical weapons.  However, modern HAZMAT 
technology does provide us with a limited ability to respond to such an incident.     
 Chemical weapons also pose a high threat for potential use by terrorist groups, but pose less of a threat of 
damaging effects than do Nuclear or Biological weapons.   This is due to the nature of chemical compounds in 
general.  While chemical weapons may have a quicker and more devastating initial effect when released, they 
don't have the wide spread effect of a biological weapon because they are not communicable agents.  There are 
no outbreaks associated with the use of chemical agents; however, they can be very lethal and cause extensive 
contamination at the site of usage.  Chemical weapons also do not possess the shear destructive power of a 
nuclear weapon.  The real threat associated with chemical weapons is the fact that chemicals are available in every 
community in the United States, making their potential for use as a weapon extremely high.  Add to this the fact 
that chemical agents have also been utilized as terrorist weapons in the past, making this a threat that should not, 
and cannot, be overlooked. 
 Explosive Devices 
 The last category of Weapons of Mass Destruction is large explosive devices, or commonly referred to as bombs. 
 These bombs may be conventional military ordinance such as missiles and aerial bombs, or improvised explosive 
devices (IED) such as large vehicle or truck bombs.  Their potential for use by terrorist groups is extremely high 
due to the fact that these types of devices are easy to manufacture, with the necessary components being widely 
available globally.  Statistics indicate that bombs are used in as many as 80% of all terrorist acts making them the 
weapon of choice, and recent trends point to the use of larger, more powerful bombs.   Examples of the use of 
such large explosive devices can be found in the incidents involving the Murrrah Federal Building in Oklahoma, 
World Trade Center in New York, the Marine barracks in Beirut, Lebanon, and the bombings of two American 
Embassies in Africa.  The difference between explosive devices and other Weapons of Mass Destruction can be 
found in the type of casualties produced by the incident.  Explosions create trauma and crush related injuries, 
whereas biological and chemical agents produce disease and illness through toxicosis.  Nuclear weapons also 
produce trauma related injury; however they also possess the element of radioactive contamination.  While the 
contamination factor associated with Nuclear, Biological, and chemical weapons does not exist with explosive 
devices, planning cannot overlook the possibility of large explosive devices containing a radiological, biological, or 
chemical agent.  This possibility could result in casualties being inflicted with both trauma and contamination 
related injuries. 


                                            Terrorists and Their Targets 
 It is often said that one man's terrorist is another man's freedom fighter. This statement illustrates the common 
diversity of the term "terrorism".  One person's opinion of what terrorism is may be different than that of another 
person.   So then, what is terrorism and how do we define it?  
 The Federal Bureau of Investigation defines terrorism as the unlawful use of force or violence against persons or 
property to intimidate or coerce a government, civilian population, or any segment thereof, in furtherance of 
political or social objectives. In the United States, the Federal Bureau of Investigation's definition of terrorism is 
generally the one most commonly used by government, law enforcement agencies, as well as the general public.  
This is not to say that the FBI's definition of terrorism is the absolute; however, it does define the basic concept 
in a simple and concise manner that makes it a very functional definition.  It tells us that terrorism is the use of 
violence against persons or property in the name of political or social objectives.  It is important to understand the 
distinction between the use of violence motivated by political or social reasons, and the use of violence for other 
reasons.   The use of terrorist type violence alone does not qualify as terrorism.  A disgruntled ex-employee who 
bombs his former employers building in revenge for being terminated has committed a crime, not an act of 
terrorism.  Violence must be motivated by the furtherance of a political or social agenda before it can be 
considered an act of terrorism.   This political or social element is all-important when defining what is, and isn't 
terrorism.   All violence committed which lacks this political or social element will be considered a crime. 
 Terrorism can be divided into two basic categories: international terrorism and domestic terrorism.  
Fundamentally, both of these types of terrorism are the same when it comes to the threat they present, tactics and 
weapons used, motivations, group structures, etc.  The difference between international and domestic terrorism is 
found in geographical location.  
 International terrorism refers to terrorism that is perpetrated against American interest by groups or individuals 
that are citizens of a foreign country.  These terrorist groups or individuals, along with their motivations and 
ideologies, will originate and reside abroad.  These terrorists generally view America as the enemy and whether 
they attack an American target in a foreign nation or here in the United States, it will still be classified as an act of 
international terrorism.  
 Domestic terrorism refers to terrorism that is perpetrated against American interests by Americans.  These types 
of terrorist groups and individuals, along with their motivations and ideologies, originate and reside in the United 
States.  And whether they attack an American target here in the United States or abroad in a foreign country, it 
will still be classified as domestic terrorism.  Additional sub-categories of terrorism include: Left Wing Terrorism, 
Right Wing Terrorism, Single Issue Terrorism, Religious Terrorism, and the individual terrorist. 


State Directed Terrorism 
 State directed terrorism refers to acts of terrorism against American interests perpetrated by groups or individuals 
operating as agents of a foreign government.  This type of terrorism is generally conducted by nations that 
consider The United States an enemy.  These groups or individuals will have received training, support, funding, 
and operate under the direct control of that government.  Such groups or individuals will generally be associated 
with official military or security forces of the foreign government.   The motivations for the use of terrorism by a 
foreign nation could include retaliation for military action, or political and economic sanctions used against that 
State Sponsored Terrorism 
 Terrorist groups or individuals that receive support from a host nation in the form of training, equipment, funding, 
and a base of operations, are known as being state sponsored. Terrorist groups or individuals in this category 
operate independently, and not under the control of the host nation.  The terrorist group will have no official 
connection to the host country, but may operate for the country covertly in return for the support provided.  
Nations that support terrorism may do so for many different groups of varying ideologies simultaneously.  
 Right Wing Terrorism 
 Right Wing Terrorism refers to terrorist groups or individuals whose ideologies and movements are generally anti-
government in nature.  The focus of this type of terrorism can be single or multi-issue in nature, and can include 
issues such as anti-taxation, pro-constitutional rights, anti-law enforcement, anti-federal government, etc.   
Groups that are associated with Right Wing movements include: white supremacy groups, black supremacy 
groups, hate groups, anti-tax groups, militias, etc.   
 Left Wing Terrorism 
 Left Wing Terrorism (often called special interest terrorism) refers to terrorist groups or individuals whose 
ideologies and movements are generally concerned with social issues.  The focus of this type of terrorism is 
typically single issue in nature and can include issues such as: anti-abortion, animal rights, pro-environmental, anti-
technology, etc.   
 Religious Terrorism 
 Religious terrorism is violence perpetrated in the name of some religious doctrine or belief.  This type of terrorism 
can be found associated with groups or individuals from both established mainstream religions, as well as fringe 
religious movements.  Fringe religions are generally associated with cults, while other groups are found to be 
rooted in mainstream Western, Eastern and Middle Eastern religions.  Basic examples of this type of terrorism can 
be found in incidents of violence associated with the anti-abortion movement in the United States, or with Middle 
Eastern groups who have declared Jihad (Holy War) against the United States.  Groups or individuals associated 
with this type of terrorism are found to be very dedicated to their movements and believe they are being directed 
by the word of God in most cases.  This type of terrorism can be international and/or domestic in nature. 


 Acts of terrorism do not necessarily have to be perpetrated by a group.  A lone individual terrorist can pose the 
same level of threat as an entire group.  Some consider the threat of terrorism posed by individuals to be greater in 
some respects than that of groups.  This is due to the fact that the movements of individuals are much more 
difficult to track than that of groups.  The individual can harbor and develop his terrorist agenda and planning in 
total seclusion without the need of outside assistance.  We probably will not know of this individual's existence 
until after a terrorist act has been committed.   Individuals engaged in terrorism could range from the professional 
terrorist who makes his living working for terrorist groups or nations, to the average person living in the average 
community.  Either way, it makes this type of terrorism a very dangerous prospect for any government or civilian 
 The answer to the question "Who is a potential target of terrorism?" is an easy one. Any individual, corporation, 
organization, government, nation or civilian population located on the globe is a potential target for terrorism.  The 
problem exists in the fact that we can't accurately predict when and where the next act of terrorism will occur, or 
what the nature of that act will be.  This reality is the underlying reason for the effectiveness of terrorism as a 
psychological, as well as physical, weapon.  Even if you are not the victim of a direct act of terrorism, you're 
affected collaterally by the fear, anxiety, distrust, and uncertainty that an act of terrorism creates.  And while it 
may be true that in general anyone can fall victim to an act of terrorism, certain types of targets present 
themselves as tactically more attractive than others.  These include such targets as: 
                 *  Federal, State or Local government facilities 
                 *  Military facilities 
                 *  Public transportation systems 
                 *  Corporate and industrial facilities 
                 *  Public events 
                 *  Historic landmarks 
                 *  Educational facilities 
                 *  Public utilities 
                 *  Nuclear energy facilities 
                 *  Computer systems and networks 
                 *  Food or water supplies 
                 *  Consumer products 
                 *  Agriculture and livestock 


                          BioCrime and ChemiCrime: A New Threat Paradigm 
 The threat we face from Weapons of Mass Destruction is typically associated with a terrorist action or an act 
carried out by a foreign nation.  The vast majority of our current thought regarding the problem of Weapons of 
Mass Destruction (WMD) is directed toward this end.  In addition, the bulk of our current preparedness activities 
center around response to an attack perpetrated by terrorists or foreign governments.    In general, this way of 
thinking is both valid and necessary because terrorists or foreign nations that desire to use these types of weapons 
against us present a very real threat.  Weapons of Mass Destruction were designed to be used as tactical weapons 
in the theater of war.  Terrorism, which many consider an act of war, has is roots grounded in a division of 
conventional warfare primarily known as Psychological Warfare.  Terrorism has always been considered a tactic 
of military strategy throughout the history of warfare itself.  But as time moves forward, all things tend to evolve, 
as they always seem to do.   
 Today, terrorism is defined as the use of force to bring about social or political change.  No longer considered 
only a military concept, terrorism has become a tactic used by many special interest movements that are grounded 
in social and political issues.  This is how we view terrorism today because that is how we define it.  Acts of 
terrorism perpetrated against American interest and citizens can bring about serious repercussions directed toward 
the offender.  The United States government considers terrorism a very serious issue and response planning is 
geared toward utilizing vast federal resources for both crisis and consequence management of such incidents.  
These federal resources would be readily available to assist any U.S. community that has become the target of a 
terrorist attack.  This current government preparedness paradigm, while comprehensive, fails to address the 
following scenario; the use of a Weapon of Mass Destruction for purposes other than terrorism. 
 It must be remembered that terrorism is a concept. A Weapon of Mass Destruction is just that, a weapon.  So 
what happens when such a weapon is utilized by an individual or group motivated by reasons other than 
terrorism?  The answer to this question is that a crime occurs. While biological and chemical terrorism are 
concepts familiar to both the public and emergency response community, the concepts of BioCrime and 
ChemiCrime are new and not widely spoken of or planned for.   These concepts present us with an entirely new 
threat that will challenge our standard way of preparing for incidents involving Weapons of Mass Destruction.  
While it is true that terrorism is in fact a crime, acts of terrorism result in specific responses that have not been 
designated for an act of criminality.  For example, if a terrorist group introduced a chemical weapon agent into an 
office building injuring 50 people, the act would fall under the jurisdiction of the federal government due to 
terrorism being a federal crime.  The Federal Bureau of Investigation (FBI) being the lead agency in charge of 
investigating acts of terrorism would be able to call into use extensive government resources to manage the 
incident.  On the other hand, what if a disgruntled employee injured 50 coworkers by introducing a chemical agent 
into their former employer's office building in retaliation for being terminated from a job?  Would this type of 
incident, which is technically classified as an act of workplace violence, result in the deployment of these 
extensive federal resources?  More than likely, such an incident would not result in a response from federal 
authorities beyond standard investigative and technical assistance.  This is due to the fact that current response 
planning addresses incidents of terrorism, not criminal uses of these types of agents.  However, if this type of 
workplace violence scenario could be classified as a disaster, then certain state and federal resources could be 
deployed to assist local responders. 
 While this point could be an issue of debate, it is meant to illustrate the importance of understanding that biological 
and chemical agents could possibly be used for reasons other than to make social or political statements. 



The concepts of BioCrime and ChemiCrime are important to consider from the perspective of local emergency 
response planning.  Motivations for criminal activity can include revenge, financial gain, vandalism, psychopathic 
fantasies, etc.  Motivations such as these, combined with a biological or chemical weapon, could present the 
emergency response community with problems beyond their normal response planning.  For example, training 
scenarios designed to illustrate the threat from biological and chemical agents typically depict situations such as, a 
plane flying over a city spraying an agent, or the city's water utility being tampered with, etc.  While these 
scenarios do depict possible methods of attack, they are based on models that represents mass area contamination 
similar to that of a military weapon deployment.  Preparedness for civilian communities must include these types 
of possible attacks from other nations, but should also include scenarios that represent trends in our own society. 
 Consider the fact that standard riot control agents, such as pepper spray, are classified as chemical weapons.  
Now think about how frequently an incident occurs involving the release of these chemical agents into buildings 
or schools causing mass evacuations and injured victims.  These events occur many times annually in 
communities across America and collectively affect thousands of individuals.  However, these events are not 
considered to be, or reported as, chemical weapon attacks that indeed they are.  What these types of incidents are 
not is terrorism.  They are criminal incidents involving the use of a chemical agent as a weapon.  These events do 
not result in the deployment of state or federal resources, but are handled by the local emergency response 
community.  The next obvious question is, what happens if the next time such an incident occurs the weapon 
agent of choice isn't pepper spray, but a nerve agent?  Would our current response protocols be adequate to 
handle such an incident?  Are we as a society prepared to respond not only to acts of terrorism, but to a wide 
range of criminal scenarios involving biological and chemical agents used as weapons?       


                             United States Domestic Preparedness Initiatives 
The U.S. Department of Justice (DOJ), through the Federal Bureau of Investigation (FBI) is tasked with 
coordinating the domestic preparedness programs and activities of the United States to ensure that a coordinated 
crisis and consequence management infrastructure is established to address the Weapons of Mass Destruction 
threat.  To accomplish this task, a federal interagency group known as the National Domestic Preparedness Office 
(NDPO) was formed.  Headquartered at the FBI offices in Washington, D.C., the NDPO serves as a single point 
of contact and clearinghouse for all WMD related information.  While not tasked with any incident response 
duties, the NDPO functions as a communication link for the emergency response community and assists with 
training and equipment issues.  The National Domestic Preparedness Office is composed of representatives from 
the following federal agencies: 
      *  Federal Bureau of Investigation (FBI) 
      *  Federal Emergency Management Agency (FEMA) 
      *  Department of Energy (DOE) 
      *  Environmental Protection Agency (EPA) 
      *  Department of Health and Human Services (DHHS) 
      *  Department of Defense (DOD) 
 Preparedness Training 
 In an effort to respond to the growing concerns of terrorism involving Weapons of Mass Destruction, the United 
States Federal Government developed a comprehensive domestic preparedness program aimed at strengthening 
our emergency response capabilities for such incidents.  This domestic preparedness-training program was 
formed under a 1997 Defense Authorization Bill (Public Law 104-201 dated September 23, 1996), which is now 
commonly referred to as the Nunn-Luger-Domenici legislation.  This legislation appoints the U.S. Army Soldier 
and Biological Chemical Command as the lead Department of Defense agency responsible for providing this 
preparedness training to the nation's emergency response community.  This training initiative is being coordinated 
by a federal interagency team comprised of representatives from the following U.S. Government agencies: 
      *  Federal Bureau of Investigation (FBI) 
      *  Federal Emergency Management Agency (FEMA) 
      *  Department of Energy (DOE) 
      *  Environmental Protection Agency (EPA) 
      *  Department of Health and Human Services (DHHS) 
      *  Department of Defense (DOD) 
 This training is designed to provide emergency response personnel in 120 U.S. cities with fundamental knowledge 
of the aspects associated with Nuclear, Biological, and Chemical terrorism.  Utilizing a train-the-trainer approach, 
the focus of this program is to prepare local emergency trainers in a way that will then enable them to train their 
individual departments.  Training courses are divided into 7 specific areas of concern: 
      *  Emergency Responder Awareness course (4 hours) 
      *  Emergency Responder Operations course (4 hours) 
      *  Technician - HAZMAT course (12 hours) 
      *  Technician - Emergency Medical Service (EMS) course (8 hours) 
      *  Hospital Provider course (8 hours) 
      *  Incident Command course (6 hours) 


      *  Senior Officials Workshop (4.5 hours) 
In addition to these training courses, this federal initiative also makes training equipment available to local 
emergency response departments wishing to develop their skills.  These Training Equipment Sets are divided into 
four primary categories: protective equipment, detection equipment, decontamination equipment, and training aids. 
 This training equipment is provided to the individual city during the week of their scheduled training.  After the 
city has conducted their training and assessed their individual preparedness requirements, they can submit an 
official request to the Department of Defense to obtain this equipment.  If approved by DOD, the equipment will 
then be made available to the city on a loan agreement.  This program provides U.S. cities with an excellent way 
of obtaining quality equipment and training materials which are specifically designed for terrorism response 
 Medical Preparedness 
 The Department of Health and Human Services (DHHS) is the lead federal agency responsible for all health, 
medical, and health related social services under the Federal Response Plan for catastrophic disasters.  The DHHS 
Office of Emergency Preparedness (OEP) coordinates all health and medical response and recovery activities, 
working with other federal agencies and the private sector.  The Office of Emergency Preparedness leads the 
National Disaster Medical System (NDMS), a partnership of four federal agencies including; Health and Human 
Services (HHS), Department of Defense (DOD), Department of Veterans Affairs (VA), and the Federal 
Emergency Management Agency (FEMA).  The National Disaster Medical System has three components: direct 
medical care, patient evacuation, and non-federal hospital beds.  This system comprises more than 7,000 private 
sector medical and support personnel organized into 80 disaster assistance teams stationed throughout the United 
States.  These teams can be deployed to assist with providing medical attention during disaster situations when 
local emergency response systems become overwhelmed.  These teams are designated as follows: 
      *  Disaster Medical Assistance Teams (DMAT) 
      *  Disaster Mortuary Operational Response Teams (DMORT) 
      *  Veterinary Medical Assistance Teams (VMAT) 
      *  National Medical Response Teams for Weapons of Mass Destruction (NMRT/WMD) 
 Understanding that a very rapid response would be required to counter the effects of a terrorist incident involving 
a Weapon of Mass Destruction, HHS planning includes the development of an enhanced local response capability 
know as the Metropolitan Medical Response System (MMRS).  The MMRS concept was created by a group of 
state and local experts in the field of emergency medical response that met at the request of the HHS Office of 
Emergency Preparedness in 1995.  These local MMRS systems utilize what is know as a Metropolitan Medical 
Strike Team (MMST) which becomes the first medical responder in local incidents involving the use of a Weapon 
of Mass Destruction. Comprised of local emergency medical personnel, these MMST's would be available 24 
hours a day to respond to a terrorist incident in their jurisdiction. The function of these teams would be scene 
specific medical triage, decontamination, treatment, and transport of incident casualties.  This concept was tested 
in Washington, D.C. and Atlanta, GA, and in 1997 initiated into 25 of the most populated U.S. cities.  The goal of 
the MMRS program is to establish a unit in each of the 120 U.S. cities chosen to receive the federally sponsored 
domestic preparedness training. 



                                                Anatomy of an Incident 
 Due to the nature of a biological and chemical weapon attack, our response planning must address two 
fundamental aspects.  First, response plans must be developed through a viewpoint of public health.  These types 
of weapons do not destroy buildings; they infect or contaminate people causing illness, injury, or death. The 
second aspect is one of general public safety.  Government and law enforcement agencies must understand both 
the physical and psychological impact that this type of incident may have on the general public, as well as the 
overall security of the environment. A terrorist incident of this nature has the potential to cause widespread fear 
and panic among the public.  This emotional response from the public may result in a breakdown in public order. 
Government, on all levels, should prepare to address this reality and develop plans for reestablishing trust and 
reducing the fear and panic being experienced by the public.  Quick and honest dissemination of information will 
be effective in assisting with this task.  The news media should deliver reports that are factual and designed to 
educate, not capitalize on the situation.  This is why government must be prepared to address details of the 
incident in an extensive manner.     Although the mechanisms of action may vary slightly between biological and 
chemical agents, the results are usually the same- large numbers of medical casualties.  We will briefly examine 
how such an event may affect the average community. 
 Biological Scenario 
 Biological Weapons produce disease, that's their mechanism of action.  The primary routes of exposure would be 
inhalation or ingestion.  Properly disseminated, the effects of biological warfare agents may not be seen for days, 
or even weeks, after the initial attack has occurred. This is due to the natural incubation period associated with 
biological organisms. Incubation period refers to the time required for the biological organism to develop inside the 
body and manifest disease.  Incubation periods for individual organisms vary and can range from 72 hours to 14 
days, depending upon the type of organism and the health of a person's immune system.  This fact makes 
biological terrorism much harder, if not impossible to detect.  Theoretically, a terrorist could disseminate a 
biological agent infecting a civilian population, escape afterwards, and be on the other side of the globe before we 
even knew what happened.  Once the effects of the biological agent begin to surface in the community, it is 
possible that large numbers of people will have been infected, become symptomatic and begin to seek medical 
attention.  The numbers of infected people would depend upon the type of biological organism used.  For 
example, it has been estimated that the proper dissemination of as little as one pound of Anthrax would be enough 
to kill the entire population of a major city.   
 Once the incubation period is over, the illness would begin to quickly surface among the citizens of the 
community.  This would result in large numbers of people all experiencing the same symptoms.  In a worst-case 
scenario, the ill would be self-referring to local hospitals, personal physician's offices, outpatient care facilities, 
pharmacies, etc. at an alarming rate.  Police and Fire department telephone systems, and / or 911 emergency 
systems, would be overloaded with requests for assistance.  Local Emergency Medical Service (EMS) providers 
may not have adequate personnel or ambulances to respond and transport all the victims calling for assistance.  
There would be an increased need for Personal Protection Equipment, medications, and medical and other support 
equipment, such as ventilators, that may not be readily available in the aftermath of the incident.  Hospitals will 
have overcrowding, not just from the truly ill victims, but also from many unaffected people that have various 
nonspecific symptoms, or fear they are infected. The need for extensive and prolonged medical services would be 
required citywide. 
 In the event that large numbers of patients, exhibiting similar symptoms, present to local Emergency Departments 
within a short period of time, Emergency physicians need to have a high index of suspicion that an attack of a 


biological agent has occurred.  The same holds true for private physician's offices receiving unusually large 
numbers of patients exhibiting similar symptoms. Health Department officials would have to begin a quick and 
extensive investigation directed toward identifying the biological agent, its method of transmission, and its origin.  
At the same time, disease onset in a community would be rapid and treatment may need to be implemented quickly 
to have any effect on mortality, or to ensure effective prophylaxis by implementing PPE, antibiotic therapy, or 
vaccinations if available.   
  Some biological agents are communicable, some are not.  In an incident involving a communicable agent, an 
ordered quarantine may be required to stop the possible spread of disease.  Non-communicable agents generally 
do not require quarantine.   The possibility of a quarantine following a biological weapon attack may exhaust both 
hospital and public health resources and personnel. Law enforcement agencies may also become taxed by 
assisting with an ordered quarantine, in addition to maintaining public order and conducting an investigation into 
the incident.  Problems would also arise with the handling and storage of the deceased, requiring the need for 
additional mortuary facilities.  In addition, fear and panic among the population is a very real possibility that must 
be considered following such an incident.  An effective method of disseminating public health information would 
be necessary to inform the public as to what action is being taken, and where to seek medical attention.    
 Chemical Scenario 
 The second scenario we will examine is the possible effect to the community caused by the release of a chemical 
warfare agent.  In general, the effects are similar to that of an incident involving the use of a biological agent with 
a few exceptions.  Chemical warfare agents are disseminated in much the same manner as the biologicals, with 
the primary route of exposure being inhalation or absorption through the skin.  If properly disseminated, the 
effects of a chemical warfare agent would occur quickly and produce large numbers of contaminated casualties at 
the site of release.     The effects of chemical agents are generally more rapidly occurring than biological agents.  
The effects of a chemical agent may appear within minutes to hours after contamination.  The specific effects 
produced would depend upon the agent involved.  These effects may, or may not be, immediately incapacitating in 
nature. Since the effects of chemical agents occur quickly, identification of the site of release and time of attack is 
more easily accomplished.  Police and emergency responders should be able to isolate and secure the scene after 
evacuating people from the area. Having the ability to quickly locate and isolate the site of release should limit 
additional exposure and aid in the investigation process.  
 Winds may carry the agent beyond the site of release, contaminating others.  Fear and panic among the victims 
affected should be anticipated.    Victims that flee the site of the incident would be self-referring to local hospitals, 
personal physician's offices, outpatient care facilities, pharmacies, etc. at an alarming rate. Analysis from similar 
incidents in the past have indicate that as many as 75% of persons involved in such as event would leave the 
scene prior to the arrival of emergency responders.  As news reports of the attack surface, fear and panic among 
the general public should also be anticipated. This will more than likely result in large numbers of citizens reporting 
to local hospitals with the belief they too have been contaminated.  The need for extensive medical services and 
decontamination at both the site of agent release and local hospitals will be required.  In addition, there will be an 
increased need for Personal Protection Equipment (PPE), medication and antidotes, decontamination, medical 
transportation, and other support equipment that may not be readily available in the aftermath of the incident.  
 The possibility of quarantine for chemical agents may not be necessary due to the non-communicable nature of 
these agents.   However, cross-contamination from man to man is possible with many of these chemical agents. 
Problems may still arise with the handling of the deceased and the need for additional mortuary facilities.  
Hospitals will have overcrowding, not just from the affected victims, but also from many unaffected people that 
have various nonspecific symptoms and believe they may have been contaminated.  Emergency response 



personnel and police would likely be taxed throughout the initial phases of the incident due to the large numbers of 
victims requiring assistance.  However, the situation could improve in as little as a few hours considering the non-
communicable nature of chemical agents, and if no additional attacks occurred.  
 These two brief scenarios are fundamental illustrations of how a community may be impacted by a terrorist act 
utilizing biological or chemical weapons.  It should be remembered that the points outlined in this text only partially 
portray the complexity and potential problems that might be encountered during one of these types of incidents. 


                                    Hospital Mass Casualty Incident Management 
One of the biggest challenges in a disaster is the managing of resources. Typically, there is not a shortage of 
available medical resources.   Most problems encountered in disaster response occur due to failure in the 
coordination and appropriate utilization of these resources.  Over the past few years we have seen hospitals, 
which were involved in disaster situations, come to realize the importance of disaster planning.  Myths such as 
disaster planning requiring large mobilization of resources, and most medical care of disaster victims being 
provided by pre-hospital personnel have been dispelled. When in reality, disaster planning can be accomplished 
with the establishment of an Incident Command System (ICS) and standard operating procedures (SOP's).  The 
following are some specific areas of concern that should be addressed through planning. 
 Training of hospital personnel in awareness and understanding of the nature and effects of biological and chemical 
terrorism is vitally important to effectively plan a response.  Not only should medical professionals be involved in 
this training, but support departments such as Security, Maintenance, Housekeeping, and any other department 
that presently plays a role in responding to Mass Casualty Incidents should also be involved.  Nursing units who 
may be receiving these patients for more definitive care should receive awareness training.  The level and degree 
of training will, of course, vary between these departments as each of their roles are defined.    Training must 
include, but is not limited to: 
      *  biological and chemical agent characteristics, effects, and treatment protocols 
      *  mass casualty incident planning 
      *  operational safety and security 
      *  critical incident stress 
      *  public and news media relations 
 Training for such departments as Security, Maintenance, and other departments that may be assigned the task of 
transportation of victims to appropriate care areas should also include: 
      *  personal protective equipment 
      *  mass casualty triage / decontamination operations 
Emergency Department Response 
 Most hospitals have an established HAZMAT team that is properly trained in the use of protective clothing and 
respirators.  These teams are specifically designed to respond, decontaminate when applicable, and manage 
chemical spills that occur within the hospital.  With such a highly developed team in place, why would hospitals 
need any additional response planning?  Let's examine an incident of chemical release that occurs at 1:00 am and 
involves 150 contaminated victims.  As we have mentioned previously, prior incidents have shown that up to 75% 
of victims leave the scene and seek medical attention on their own.  These victims may arrive at the nearest 
Emergency Department before the Emergency Department has even been notified that an incident has occurred.  
If Security and Emergency Department personnel are not properly trained in awareness and maintain a high degree 
of suspicion, these contaminated victims may obtain entrance into the hospital posing a threat to the health of 
visitors, other patients, and employees.  Furthermore, to properly begin treatment of these victims, triage and 
decontamination procedures must be immediately initiated.  This would require Emergency Department personnel 
to have the proper equipment, training, and response plans in place.  This is not to say that established internal 
HAZMAT teams have no place in Mass Casualty Incident planning.  A more appropriate approach may be to 


involve the internal Hazmat team as support personnel who can take over decontamination activities once they 
arrive at the Emergency Department.  This would in essence free up the Emergency Department personnel to 
continue the triage and treatment aspects involved in an MCI.             
 Command and Control 
 During large Mass Casualty Incidents (MCI), the hospital's Crisis Management Team (CMT) will most likely be 
activated.  The Crisis Management Team (CMT) will function as the command and control element of the 
response operation.  The CMT will be responsible for providing overall leadership, coordinating the efforts 
between hospital departments and outside agencies that are providing assistance, handling operational logistics & 
legal issues, disseminating information to the public, in addition to a wide range of other administrative duties.   
The Crisis Management Team (CMT) should operate from an established command center on site.  This 
command center should be identified in advance and located away from the major operational aspects of the 
response effort.  The command center must afford the CMT members an environment of security and quiet in 
which to concentrate on critical decision making and conduct planning activities.  Security and access control 
must be maintained at the command center at all times during the incident. 
 Since information is key to the decision making process, the Incident Command Center (ICC) should be equipped 
with multiple (multi-line) telephones, fax machines, handheld radio communications, computers with access to 
both the Internet and the hospital's Intranet, television, copiers, writing supplies, copies of all disaster planning, 
inter-departmental telephone directories, policy and procedure manuals applicable to disaster response efforts, etc. 
 Each CMT member should to equipped with a personal pager, cellular telephone, and handheld radio.   
 Information flowing into the command center must do so through an established procedure.  The average size of 
a Crisis Management Team (CMT) is between 5 and 10, with each member being responsible for a particular 
aspect of the operation.  The size of a given CMT may vary depending upon the size and administrative structure 
of an individual hospital. Operational aspects a Crisis Management Team must consider would include:  command, 
logistics, operations, legal, information, public relations, finance, safety & security, inter-agency liaison, or any 
other aspect important to an individual organization.  Since a Crisis Management Team (CMT) is composed of 
such a limited number of people, restrictions must be placed on who can provide information to the command 
center.  It should be obvious that if all persons involved in the response effort had the ability to contact the 
command center directly, the CMT would be overwhelmed in a short time.  The standard procedure for 
information exchange during the incident should be: employees report to supervisors; supervisors report to 
department heads; department heads report to the CMT.  This procedure should also work in reverse.   All 
communications with the news media should be arranged through the CMT.  
 The standard incident management system used by most government agencies and emergency response 
organizations is the Incident Command System (ICS).  The Incident Command System (ICS) is a simple 
management structure that is built around five major operational areas; incident command, logistics, planning, 
operations, and finance/administration. Each operational area has one individual that is in charge of the activities of 
that section and this individual reports directly to the Incident Commander, who is in charge of the entire 
operation.  This form of simple management allows for an effective flow of information and operational 
resources.  It also allows for multiple incident response efforts to be coordinated under one unified command 
activity, without sacrificing command and control of those individual response efforts.  Hospitals should study the 
Incident Command System (ICS) and consider developing a crisis management system that resembles it.  This 
will allow the hospital's Crisis Management Team and it's response efforts to be easily coordinated with that of 
other emergency response organizations. 



Security Operations 
 Security & Safety will be an issue of great importance during a hospital MCI operation.  Situations requiring 
crowd control, traffic control, building protection, etc. should be anticipated in the aftermath of a terrorist event.  
The hospital security team will be responsible for several key functions during the MCI operation.  The Hospital 
Administration, along with the Emergency Department must identify the security aspects that are required to assist 
in its operation and coordinate with the Security Department to have these requirements addressed.  The following 
are key issues of consideration: 
      *  Scene security around the triage and decontamination areas, including access control.  The issue of 
          security for the triage and decontamination areas cannot be overlooked during the planning or deployment 
          stages of an effective MCI operation.  It will be necessary to establish operational HOT, WARM, and 
          COLD ZONES within areas of patient triage and decontamination.  The operational integrity of these 
          ZONES must be maintained at all times to insure that the safety of medical personnel, patients, 
          responders, and visitors remains consistent.  Maintaining security of HOT, WARM, and COLD zones 
          should include the application of boundary markers such as barricades, caution tape, etc. along with 
          warning signs to define HOT LINES, WARM LINES, and COLD LINES.  
      *  Access Control procedures must be established at all other hospital entry points to insure that 
          contaminated incident casualties do not enter the facility prior to triage and proper decontamination.  The 
          importance of this issue cannot be stressed enough.  Contaminated victims searching for help that are 
          allowed entrance to the hospital threaten the safety of visitors, patients, and personnel and may threaten 
          the viability of the hospital to maintain an open facility for further treatment of casualty victims.   
      *  Traffic control of Emergency Service and all other vehicles entering or departing the Emergency 
          Department triage receiving and parking areas, including the separation of patients arriving from the MCI 
          scene in private vehicles from other non-MCI related patients. 
      *  Crowd control of personnel, visitors, spectators, etc. around the triage area, decontamination area, 
          vehicle entrances, visitor waiting rooms, parking areas, etc.   
      *  Identification of all necessary equipment required to assist security personnel with scene security, crowd 
          control, traffic direction, etc. must be established.  
      *  The Security Department should be prepared to quickly elicit support from non-security personnel if their 
          team becomes taxed.  This can be accomplished by training personnel from departments not heavily 
          involved in the incident response to provide less demanding security related functions such as traffic 
          control.  Local security service contractors may be a source for obtaining temporary officers to 
          supplement the hospital's protection team.  The problem with deploying these types of officers would be 
          grounded in a lack of understanding and adequate training in the hospital's MCI response plan.  If 
          protection officers from outside companies are employed to re-enforce the hospital's team, they should 
          only be assigned to non-critical security support functions.  Proper supervision of, and communication 
          with these officers, must be maintained at all times to insure integrity of the security plan.   
      *  Security personnel should receive, at a minimum, awareness level training with regards to the threat of 
          biological and chemical terrorism, biological and chemical agent characteristics, overall hospital response 
          planning, and community response planning.  This type of training should afford hospital protection 
          officers with the fundamental understanding of the threat in which the hospital faces.  More specific 



         training should be administered to these officers regarding the Emergency Department (ED) triage and 
         decontamination operations security, general facilities security, traffic control, crowd control, news 
         media, Personal Protection Equipment (PPE) requirements, communications, public relations. 
 Fulfilling the requirements for effective operational communications can be a difficult task at a minimum.  Pre-
planning will ensure that such an important aspect of Mass Casualty Incident (MCI) response will not be 
forgotten.  Employees tasked with operational responsibilities must have the ability to communicate with each 
other, support departments, hospital management, and the public.  The effectiveness of operational 
communications will depend upon an individual hospital's advance planning and available equipment resources.  
Two fundamental mediums for communications are the telephone and two-way radios.  Telephones will be widely 
available in the workplace; however they are not very portable unless they are cellular.  Two-way radios are ideal 
for portable communications; however, they are usually not present in sufficient numbers, if present at all. 
Advance planning should identify the proper communications equipment needed for all operational aspects of the 
Mass Casualty Incident (MCI) plan.  Once equipment issues have been identified and addressed, procedures for 
an effective flow of information should then be established.  
 The Emergency Department (ED) will provide the bulk of the direct patient services during the MCI operation.  
The ED will likely conduct the triage and decontamination operations, as well as initial patient treatment.  During 
an MCI operation, the ED staff will usually be divided into these three working groups; triage staff, 
decontamination staff, and patient treatment staff.  It will be critical that these three working groups be able to 
communicate with each other at all times.  In addition, the ED staff must be able to communicate with support 
departments within the hospital.  Two-way radios would allow for effective communications between ED staff 
members working their various assignments, especially triage and decontamination.  Considering that triage and 
decontamination operations will generally occur outside the treatment areas within the ED, relaying information via 
two-way radio would be efficient.  Emergency Department staff providing patient treatment inside the facility 
would have access to telephones and could relay request for support from staff working triage and decon.  Staff 
members assigned to triage and decontamination operations must also have the ability to clearly communicate with 
arriving Emergency Services personnel and patients.  The ability for triage and decon staff members to clearly 
communicate may be hampered by Personal Protection Equipment (PPE) being worn. If persons arriving at the 
triage and decon areas can not clearly understand instructions being issued by ED staffers, due to PPE, then 
problems could arise.  This reality must be considered and addressed in advance.  Ways of countering the 
negative effects PPE may have on communications include utilizing megaphones and / or written instructions 
posted on signs.   
 Another area in which effective communications will be important is security.  It should be obvious that all 
members of the hospital security team must be able to communicate with each other.  Hospital security will be 
responsible for providing general protection of the facility, crowd control, traffic direction, access control, etc.  If 
effective communication between security personnel is not maintained, the integrity of the entire MCI plan may be 
compromised.  Communications between security personnel and Emergency Departments must also be 
established and maintained at all times.  Emergency Department staff operating in the triage and decontamination 
must also be able to communicate with the security personnel maintaining the scene control of these areas. 



Integration of Support Departments & Services 
 The hospital Emergency Department will primarily be responsible for operational management of a Mass Casualty 
Incident (MCI) event.  However, the Emergency Department could not operate effectively without the support 
from other departments within the hospital system.  The basic function of the Emergency Department is to 
provide triage, patient decontamination, and medical treatment. While the Emergency Department's role during an 
MCI is very specific, the MCI also affects other departments within the hospital system. These other hospital 
departments also have specific roles to play in support of the MCI operation.  Hospital management must 
determine how departments within the hospital system support an MCI operation and integrate this into the 
planning.  The following departments will provide  primary support to an MCI operation.  In addition, we 
recommend integrating local emergency medical services (EMS) into the hospital MCI plan.  
      *  Engineering / Maintenance Department 
 Maintenance personnel could be called upon to supply a wide variety of support services during a disaster 
operation.  The extent to which these personnel provide support  will greatly depend upon the requirements of the 
disaster operation plan.  Maintenance personnel may be required to erect portable decontamination showers, set up 
temporary shelters such as tents, supply portable power generators, portable lighting, supply barricades for traffic 
control, etc.  In addition, these personnel may also be responsible for the clean up after the operation has ended.  
Standard HAZMAT protocols should be reviewed and upgraded to include biological and chemical weapon agents, 
if necessary. 
      *  Morgue Department 
 In Weapons of Mass Destruction incidents, the issue of processing, decontaminating, and storing of the deceased 
will be one of great importance and must be planned for in advance. Taking into consideration the very nature of 
Weapons of Mass Destruction, one should assume that if such a weapon were used, mortality rates within the 
community would rise dramatically.  This increase in citizen mortality may occur quickly if a Chemical Weapon 
agent was used in the attack, or over a period of several days in the case of a Biological Weapon attack. This 
increase in civilian fatalities may quickly overtax existing hospital or community morgue facilities.  Plans must be 
developed to insure that adequate mortuary services are available to properly handle the deceased.    
 Another issue of importance is the proper decontamination of incident fatalities.  Individuals that have died in the 
incident  must be decontaminated in the same manner as other incident casualties. Plans regarding the 
decontamination of incident fatalities should address: the location of this type of operation, who will provide the 
service, equipment requirements, records keeping, personal belongings' inventory and storage.  
      *  Linen Services  
 During an MCI involving a decontamination operation, Linen Services will play a vital role in the support of the 
Emergency Department.  Decontamination operations will require an extensive amount of towels and patient 
gowns.  Large numbers of bed linens will also be required to support the Emergency Department's patient 
treatment operation.  A large stock of towels, bed linens and patient gowns should be pre-positioned in the 
Emergency Department for immediate use in the event of an MCI requiring a decontamination operation.  This 
pre-positioned supply should be adequate to support a decontamination operation for at least 50 patients initially, 
with a plan to continuously re-supply the decontamination operation.  Coordination between Linen Services and 
the Emergency Department will be essential to insure that an adequate supply of linens are always available.   


              *  Social Services 
 The hospital Social Services Department will also play a vital role during MCI events.  During any disaster, 
emotions can run high.  Stress, fear, panic, confusion,  anger, rage, paranoia, etc. are all  common emotions felt 
by those who have been involved in a disaster situation.  This holds true for  incident victims, family members, 
and emergency response workers alike.  Social Service professionals can assist greatly in the disaster relief effort 
by providing victims, family members, and staff with information ranging from emotional support to mental health 
needs.   Social Service workers should be prepared to handle requests for pastoral services, victim services, 
emotional or stress counseling, etc.  A list of organizations and professionals providing these types of services 
should be created for distribution during the crisis.   
              *  Local Emergency Medical Services (EMS) 
 Emergency Medical Services (EMS) can include full time city / county rescue services, volunteer rescue 
departments, or private ambulance services. Once your hospital's Mass Casualty Incident  (MCI) planning has 
been completed, all local Emergency Medical Services (EMS) should be introduced to the plan.  The goal is to 
develop understanding and coordination between the EMS services transporting casualties and the hospital 
receiving these casualties.  Mass Casualty Incidents evolving from an act of terrorism are likely to be stressful and 
confusing, at both the incident site and the hospital. In order for the response operation to be as efficient and 
effective as possible, everyone involved should know the  other's planning.  This can be accomplished in two 
basic ways.  EMS personnel should be invited to the hospital to review planning and survey the triage, ambulance 
receiving area, decontamination areas, etc.  Or the Emergency Department could develop a presentation outlining 
the hospital's plan and deliver it to local EMS services.  No matter which method is used to present this 
information, local EMS responders must have a clear understanding of the hospital's plans and procedures for the 
medical response to MCI's resulting from an act of terrorism.   



 We have acknowledged the fact that the possibility of biological or chemical agents being used against the citizens 
of the United States is a very real threat. Both governmental and private sector analysis echo the validity of such a 
threat, making the issue of biological and chemical terrorism the most important public safety and health concern 
of our time.  Biological and Chemical Weapons of Mass Destruction  wielded against an unknowing and 
unprepared society could very well result in a situation of nightmare proportions.  Considering the fundamental 
underlying concept of terrorism almost ensures that we will never know in advance when and where such an 
attack will occur.   While it is true that to date, significant acts of biological or chemical terrorism have not 
occurred in the U.S., we must always bear in mind that no community is immune to this form of violence.  
Therefore, shouldn't we think a little more in depth on the subject of domestic preparedness?    
 As we know, terrorism of this proportion is a new concept to most Americans. We hear about such acts 
occurring in other countries and think how tragic for those people to have to endure such senseless violence.  We 
have sat in our homes and felt helpless as we watched acts of violence play out on our televisions that have 
occurred right here in the United States.  Now that our threat paradigm has changed, we must begin thinking in 
new ways.  One of the  most important ways this new threat should be viewed is through the eyes of public 
health.  Biological and chemical weapons do not destroy buildings, they infect and contaminate people.  Who are 
these citizens at risk?  You, me, our families, friends, neighbors, co-workers, etc.  Our planning must not 
overlook the true public health risk associated with this type of terrorism.  Our responses to this emerging threat 
cannot be viewed in the same context as our response to more traditional acts of terrorism, such as bombings.  
More than likely, acts of biological and chemical terrorism will not be accompanied by a "bang".     
 As we have outlined in this report, preparation for such events must begin with the understanding of terrorism 
and the weapons at their disposal, followed by planning and training.  This preparation must be structured from 
the ground up focusing on the first line emergency responders, the EMS community and hospitals.   Federal 
Government response planning and resources provide for the backup of local and state responders.  The Federal 
Government and the U.S. Military will not be the initial responding entity as so often portrayed in the movies. The 
burden of first response rests heavily upon the shoulders of our local paramedics, firefighters, and law 
enforcement officers.  This burden will then be carried into our local hospitals as our second line of defense.  
Without proper equipment, training, and preparation in place, how many first responder's lives as well as citizen's 
lives will be jeopardized?  In addition, if local hospitals aren't afforded the same level of training, how will they be 
able to continue the battle?  The United States Government is spending billions of dollars and countless man-hours 
in an attempt to prepare and protect the American public from acts of terrorism.  With this in mind, do you think 
that in the interest of both public safety and national security, our government sees this as a real threat as well?  If 
not, why would so much emphasis be placed on such a threat if there were no likelihood of its occurrence?   
While we truly hope that such an event never occurs on American soil, it may.  With the presence of even a 
remote possibility, shouldn't we err on the side of preparedness? 



                                   Internet Information Resources 
  U.S. Army Soldier and Biological / Chemical Command 
 Federal Bureau of Investigation 
 Environmental Protection Agency 
 Domestic Preparedness 
 DHHS Office of Emergency Preparedness 
 Federal Emergency Management Agency 
 NBC Medical Web Server 
                                                                          2000 Protective Research Group, All Rights Reserved 


                                                  About the Authors                                     
  Wade M. Knapp, CPS 
 Mr. Knapp is President of Protective Research Group.   He is a Certified Protection Specialist with over 22 years 
experience in the protection industry, including 11 years in security management. He is a graduate of Executive 
Security International, Aspen CO, and has obtained education in Law Enforcement, Security Management, 
Executive Protection, Biological & Chemical Terrorism, Disaster Management, Basic Life Support (BLS), 
Advanced HAZMAT Life Support (AHLS), and Self-Defense.  In addition to his career in Security Management, 
he is also an experienced Bodyguard, Licensed Security Instructor, Basic Life Support Instructor, Safety & 
Security Lecturer, Safety & Security Author, a former Private Investigator, and a 1st Degree Black Belt and Self-
Defense Instructor.  He is a member of the International Association of Counter-Terrorism & Security 
Professionals, Terrorism Response Association, Association of Contingency Planners, Disaster Preparedness and 
Emergency Response Association, American Federation of Police and Concerned Citizens. 
 Lee A. Knapp, RN, CEN 
 Mrs. Knapp is Vice-President of Protective Research Group.   She is a Registered Nurse and Certified Emergency 
Nurse with over 17 years experience in the medical industry, including over 15 years in the field of emergency 
nursing.  Mrs. Knapp is a graduate of Marshall University School of Nursing, and has an extensive background in 
the field of emergency medicine.  Certifications and education include: Nursing Management, Basic Life Support 
(BLS), Pediatric Advanced Life Support (PALS), Advanced Cardiac Life Support (ACLS), Advanced HAZMAT 
Life Support (AHLS), Biological & Chemical Terrorism & NBC Terrorism medical response.  In addition, she is 
an experienced Medical & Safety Lecturer, Basic Life Support Instructor, Advanced HAZMAT Life Support 
Instructor, and Terrorism training coordinator for the Emergency Department at St. Vincent's Medical Center in 
Jacksonville, Florida. She is a member of the Terrorism Response Association, Association of Contingency 
Planners, Disaster Preparedness and Emergency Response Association  
 Protective Research Group is a private consulting firm located in Jacksonville, Florida which provides consulting 
services regarding issues of personal, corporate, and public safety and protection. For more information contact: 
 Protective Research Group 
1740 Manning Street 
Jacksonville, FL 32207 
 Telephone:  904.285.8520