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Chemical Weapons
Improved Response Program
(CWIRP)
Playbook
Guidelines for Responding to and Managing a Chemical
Weapons of Mass Destruction Terrorist Event
November, 2000
Prepared by:
U.S. Army Soldier and Biological Chemical
Command (SBCCOM)
Domestic Preparedness Chemical Team
Disclaimer
The findings in this report are not to be construed as an official Department of the Army position unless so
designated by other authorizing documents.
The use of trade names or manufacturers' names in this report does not constitute an official endorsement of
any commercial product. This report may not be cited for purposes of advertisement.
CWIRP Playbook
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Table of Contents
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Table of Contents
Table of Contents.....................................................................................................................ii
I Introduction.....................................................................................................................I-1
The Chemical Weapons Improved Response Program.....................................................I-1
CWIRP Playbook Concept...............................................................................................I-2
CWIRP Playbook Outline.................................................................................................I-2
II Pre-Incident Plans and Procedures ............................................................................II-1
Emergency Response.......................................................................................................II-2
Law Enforcement.............................................................................................................II-6
Health and Safety...........................................................................................................II-13
Emergency Management................................................................................................II-23
III Initial Response: The First Hour............................................................................III-1
Emergency Response......................................................................................................III-1
Law Enforcement............................................................................................................III-8
Health and Safety..........................................................................................................III-13
Emergency Management...............................................................................................III-17
IV Follow-On Response: The First Day....................................................................... IV-1
Emergency Response..................................................................................................... IV-1
Law Enforcement........................................................................................................... IV-6
Health and Safety........................................................................................................... IV-9
V Long-Term Response and Recovery ...........................................................................V-1
Emergency Response.......................................................................................................V-1
Law Enforcement.............................................................................................................V-1
Health and Safety.............................................................................................................V-3
VI Participating Agencies.............................................................................................. VI-1
VII Program Reports.....................................................................................................VII-1
VIII Supporting Information..........................................................................................VIII
Training Recommendations for Law Enforcement......................................................VIII-1
DPP Training Performance Requirements ..................................................................VIII-7
Letter from the United States Environmental Protection Agency
IX Bibliography............................................................................................................... IX-1
X Acronyms .......................................................................................................................X-1
Annex A Guidelines for Responding to a Chemical Weapons Incident ......................A-1
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Part I Introduction
The Chemical Weapons Improved Response Program
Background
As a result of the growing concerns regarding chemical/biological (C/B) terrorism,
Congress passed Public Law 104-201, the National Defense Authorization Act for Fiscal
Year 1997. This legislation, through Title XIV "Defense Against Weapons of Mass
Destruction," tasked the Department of Defense (DoD) to assist federal, state, and local
officials in deterrence of or response to threats or acts of weapons of mass destruction
(WMD) terrorism. This effort is commonly referred to as the Nunn-Lugar-Domenici
(NLD) Domestic Preparedness Program (DPP).
The NLD DPP called for the following:
*
The establishment of a training and exercise program that targets selected cities.
*
A national hotline/helpline program designed to receive and process inquiries from the
responder community.
*
A program designed to identify systematic deficiencies in response capabilities of the
community as a whole.
In response to the latter of these objectives, the U.S. Army Soldier and
Biological Chemical Command (SBCCOM) developed the Chemical
Weapons Improved Response Program (CWIRP). The CWIRP partnered
with federal, state, and local emergency response personnel to identify and
resolve issues involving chemical terrorist events. A detailed listing of the agencies
involved in the CWIRP process is contained in Part VI.
As the result of recent events, significant threats over the past few years, and the
increased availability and proliferation of nuclear, biological, or chemical (NBC)
materials, there is an increasing concern for the potential of terrorist incidents
occurring in the United States involving weapons of mass destruction (WMD)."
(Congressional Record, February 26, 1997, "Report on Government Capabilities to
Respond to Terrorist Incidents Involving Weapons of Mass Destruction" Message
from the President of the United States)
.
This Playbook, one of several products of the CWIRP process, serves to identify the key
issues that the program studied and provides basic recommendations and guidelines for
enhancing response and management of a chemical incident. This document, along with
the referenced material in Part VII, provides a comprehensive collection of knowledge of
the CWIRP. The Playbook and other referenced documents are designed to build upon the
DPP WMD training program awareness and operations training.
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The partners in the CWIRP process formed four functional groups to address the concerns
of responding to a chemical incident. These functional groups consist of federal, state, and
local experts in the following areas:
*
Emergency Response
*
Law Enforcement
*
Health and Safety
*
Emergency Management
The CWIRP conducted a series of exercises called
Baltimore Exercise (BALTEX) that consisted of
tabletop, functional, and workshop formats to assist
members of the functional groups in recognizing the
magnitude of a chemical incident and to identify the
key issues that needed resolution. Each functional
group, through regularly scheduled meetings and
workshops as well as the BALTEX exercises, focused
on identifying recommended procedural guidelines to
address each issue. Many
issues also required scientific studies that were conducted by SBCCOM. The Maryland
response community supported these studies to ensure that the results were operationally
effective.
CWIRP Playbook Concept
The issues covered in the Playbook are intended to be applicable to the majority of juris-
dictions across the country (large, small, metropolitan, rural). Jurisdictions and agencies
using the Playbook to assist in preparation of plans, policies, and procedures for response to a
chemical WMD incident are expected to adapt these recommendations to fit their current
level of preparedness and staffing.
The Playbook is written to be as generic as possible. Any mention or reference to an
organization or procedure specific to the Baltimore or Maryland area is strictly for
clarification and conceptual simplicity.
CWIRP Playbook Outline
The CWIRP Playbook is divided into sections that focus on the sequence of response to a
chemical incident. These sections are separated into the following areas:
*
Pre-Incident Plans and Procedures
*
Initial Response The First Hour
*
Follow-On Response The First Day
*
Long-Term Response and Recovery
Each section identifies the functional group issues and recommendations as they pertain to
that stage of the response. The subject matter experts from each functional area supporting
the CWIRP derived the list of issues; however, each jurisdiction has its own policies and
The CWIRP partnered with the city of
Baltimore to resolve issues of response to a
chemical terrorist incident.
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ways of conducting business. While there are specific functional areas in each part of the
playbook departments and agencies should take the time to scan the issues and
recommendations from each area as certain recommendations in one functional area may
reference response agencies/actions from another. Users of the Playbook should feel free
to adapt the subject matter it contains based on their own experience and expertise.
"The Face of Terrorism"
Though the global incidents of terrorism have waned in recent years, a new and disturbing pattern
has emerged. Attacks have come less often, but with far greater consequence. Tools of terror
have transformed from guns and Molotov cocktails to nerve gas, massive ammonium nitrate bombs,
and even biological weapon attacks. Long-held taboos have been broken. Coupled with this trend
is the prospect of state-sponsored terrorism or terrorist activity financed by wealthy individuals.
State sponsorship, access to significant financial resources, heightened scientific and technical
prowess, and access to information available on pathways such as the Internet may all combine to
breach the notion of a technological "glass ceiling" for terrorists. Today's terrorist has the potential
to be far more deadly than ever before.
Within the United States, the potential for the use of weapon(s) of mass destruction (WMD) by
terrorists has become a major national security concern. The spread of international terrorism has
long been a major threat, but law enforcement and intelligence officials are increasingly concerned
about the rise of groups or persons within extremist movements in the United States. Fringe ele-
ments and various persons within these extremist movements in the United States are examples of
this new threat. Bombings in Atlanta, GA, and Birmingham, AL, as well as a rash of biological agent
hoaxes in 1998 and 1999, have amplified this concern. These events and concern about the poten-
tial for WMD terrorism warrant increasing vigilance and preparedness.
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Part II Pre-Incident Plans and Procedures
The ability of an agency to respond to and effectively manage a chemical WMD incident
begins with the development of departmental plans, procedures, and training. Preparation
for responding to a chemical incident should begin with modifying existing plans and
procedures to consider and include WMD-specific operations. A chemical terrorist
incident is different from a routine HazMat incident in that the terrorist incident:
*
Is deliberate in nature.
*
Is a criminal act.
*
Is designed to produce a large number of casualties.
*
Is expected to result in a large number of fatalities.
*
Will require mass numbers of people to be decontaminated.
This section outlines the issues and recommendations that departments should consider in
advance of the actual occurrence of a chemical incident. These recommendations are based
on the assumption that individuals have a basic knowledge of chemical agent awareness
and emergency response operations. This information is provided as part of the NLD DPP
city "Train-the-Trainer" program.
Throughout the Playbook, constant reference is made to the need for
communications between the various responding agencies. This com-
munication is extremely important to the fire, police, and medical agencies
as they rely heavily on each other to successfully manage such an incident.
For this communications flow to be effective in an actual response, it must
be practiced in multiagency drills and exercises.
It should be noted that agencies should only consider operating in a
chemically hazardous environment after thorough training and with
proper equipment. Several recommendations are made throughout the
Playbook regarding roles, levels of operation, and personal protective
equipment (PPE). Departments that do not have trained and equipped personnel to perform
such operations should not enter a chemical incident scene. The importance of proper
equipment and adherence to PPE safety standards, including respirator fit-test
requirements, cannot be overemphasized.
If we have a free path, we go forward.
If we meet an obstacle, we go around it.
If the object cannot be overcome, we retreat.
When the enemy is unprepared, we surprise him.
If he is alert, we leave him alone.
Quote from the German Terrorist Group Bader Meinhoff
Multiagency commu-
nications pose a major
challenge between
local, state and federal
responders.
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General
Issue: Funding for Chemical Protective Equipment
Other than knowledge and awareness of the hazards associated with responding to a
chemical WMD incident, the major issue facing response organizations is the procurement
and maintenance of protective equipment. Studies indicate that the respiratory protection
most law enforcement agencies currently use for riot control are not suitable for chemical
agents and in some cases are prohibited from use by federal safety standards. Other
departments may not have any PPE at all (EMS).
Recommendation.
Funding for equipment necessary to respond to a C/B event may be
available through the federal grant process. The National Domestic Preparedness Office
(NDPO) developed a Standardized Equipment List (SEL) to be considered by response
agencies. Each jurisdiction should have a representative responsible for collecting and
coordinating federal grant requests, and interfacing with state grant POCs. Agencies
should contact their city or county emergency management office or Mayor or County
Executive's office to identify their representative. Many grants are now being executed at
the state level.
Issue: Terrorism Response Plans
Each department and level of law enforcement (local through state) should have a terrorism
response plan that encompasses department-specific guidelines in preparing for and
responding to acts of terrorism. These plans should also include information specific to
WMD incidents.
Recommendation.
Municipalities should develop WMD terrorism response plans after a
thorough assessment is made of their vulnerabilities. This assessment should outline and
identify key areas or events that present targets of opportunity for terrorists. Key historical
dates and events, large public gatherings, and locations or meetings with political, social, or
ethnic agendas are only a few of the targets likely to provide terrorists a means to present
their message. Many states and jurisdictions are conducting these assessments as part of a
DOJ grant process.
Plans should outline specific notifications that are to be made once an act of chemical
terrorism occurs. These should include local, state, and federal law enforcement agencies
as well as local notifications necessary to support the response. Typical types of local
notifications may include medical treatment facilities, local health department, fire
department, HazMat teams, city and county emergency management, and nearby military
bases. Any act of suspected terrorism should be reported immediately to the nearest
Federal Bureau of Investigation (FBI) field office. FBI field offices have appointed agents
to perform as WMD coordinators for their region. Additionally, field offices supporting
the larger metropolitan jurisdictions have trained and equipped these agents to perform
limited HazMat operations in support of the local jurisdiction until the arrival of more
specialized elements such as the FBI Hazardous Materials Response Unit (HMRU).
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Issue: Recall of Emergency Response Personnel
Private ambulance corporations, security agencies, and volunteer fire companies often have
a population of part-time civil servant employees who hold full-time positions at other
emergency agencies (e.g., police, fire, EMS). During a disaster, many of these people will
be recalled to their primary job. This loss of manpower will hinder the ability of private
companies to respond to the normal day-to-day operations and leave them unable to
provide requested backup to the incident site. Additionally, many of these individuals also
hold positions in their State National Guard. This is particularly true in the security, law
enforcement, and medical areas.
Recommendation.
Agencies should have an accurate count of their personnel who
provide emergency service in other capacities. Having a solid understanding of their
resource status during a crisis is paramount to supplying a service during a disaster.
Coordination should be made with the State National Guard Headquarters to determine what
their recall procedures will be in the event of a local MCI. Several have already determined
that they will not recall their personnel who fill emergency positions in the community. They
would rather allow them to continue to provide support as part of the community's resources.
This, however, should be verified within each jurisdiction and not assumed.
Emergency Response
Issue: Training
Emergency responders (e.g., fire, police, medical) must be trained and prepared to handle
any emergency. The responder should have, as a minimum requirement, training that
consists of or is equivalent to the awareness and operations level training from the DPP
Train-the-Trainer course. All personnel must be aware that a terrorist event can happen
anytime anywhere.
Recommendation.
Responding to a mass-casualty chemical WMD event will place
standard firefighters in positions of possible chemical exposure that are normally only
experienced by trained hazardous materials (HazMat) operators. All emergency response
agencies should have a designated training officer who will be responsible for all aspects of
training and updated information. Recommended training includes PPE, positive pressure
ventilation (PPV), decontamination, the use of chemical detectors, and chemical agentinformation. The reports developed by the Domestic Preparedness Improved Response
Program are excellent references and are readily available via the SBCCOM Web site
(http://www2.sbccom.army.mil/hld).
Additional training areas and recommendations can be obtained from the training
performance requirements outlined for the Domestic Preparedness city training program.
These objectives are listed in Part VIII of this document.
Additionally, any chemical terrorist event will require close cooperation between the fire
and law enforcement agencies involved. These agencies should work together to conduct
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joint training exercises that focus on the supporting roles that each must accomplish to
ensure an effective and safe response.
Issue: Personnel Protective Equipment For Fire / EMS / HazMat
One important aspect of response to any chemical incident is the
assurance of proper personal protection equipment for all
responders. Test and evaluation studies completed by SBCCOM
on PPE have suggested that fire and emergency medical services
(EMS) personnel may use firefighter turnout gear with self-
contained breathing apparatus (SCBA) as minimal protection
against chemical agents for quick response. The responder must
realize that this practice in no way replaces the requirements for
PPE for HazMat operations. This practice is only to be used for a
limited timeframe and considered as an alternate means of quick
rescue of
known live victims
.
Rescue personnel may be required to use specialized rescue equipment in addition to
standard firefighter turnout gear. This equipment may include rescue helmets, harnesses,
gloves, and ropes. Rescuers must use caution to protect such equipment from being directly
exposed to liquid chemical contamination. EMS personnel, in addition to full turnout gear
and SCBA, must also use additional EMS personal protection as required. This includes
eye protection, butyl rubber gloves, and respiratory protection against not only chemical
agents but also bloodborne pathogens and contagious diseases. HazMat technicians should
operate in their normal levels of protection based on the chemical threat for HazMat
operations.
Recommendation.
All responders should be trained in proper use and types of PPE for
any chemical agent incident appropriate for their role and responsibilities in a response.
SCBA is the suggested type of respiratory protection equipment for all fire, EMS, rescue,
and HazMat personnel. The SBCCOM report,
Guidelines for Incident Commander's Use
of Firefighter Protective Ensemble (FFPE) with Self-Contained Breathing Apparatus
(SCBA) for Rescue Operations During a Terrorist Chemical Agent Incident,
is an excellent
guideline to use for rescue operations on a chemical agent incident. The Emergency
Response Functional Group also recommends that all emergency responders receive the
basic WMD Awareness and Operations Training developed by the DPP. A list of DPP
performance requirements are included in Part VIII of this document.
Issue: DecontaminationA chemical WMD incident may result in a massive number of people who may require
decontamination. For decontamination to be effective, it must be rendered immediately.
Firefighters need to be trained and prepared to perform mass-casualty decontaminationprior to an incident.
CWIRP studies indicate that
turnout gear with SCBA pro-
vides sufficient protection to
conduct rescue of live casualties
with minimal risk to firefighters.
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Large volumes of water are necessary
to have any effect on removing agent
from the skin.
Incident casualties will need to be prioritized for decontamination based on the likelihoodof exposure. Additionally, emergency medical triage must be performed to ensure that
those requiring immediate or urgent medical care are administered to first.
After emergency triage and prioritization of casualties, the first step of
decontamination is to remove as much clothing as the casualties willallow. Studies indicate that up to 80 percent of the contamination on a
victim will be removed by disrobing. Convincing the populace to doso will be a challenge to responders. It is also essential that the
responders provide as much privacy and gender segregation as possible
based on the resources available and amount of agent exposure to the
victims.
A bleach solution is not recommended for mass-casualty
decontamination operation by civiliam responders because of thesefactors:
*
Bleach solutions may degrade the skin surface allowing greater penetration of the
chemical warfare agent (CWA) into the body.
*
Flushing with
large volumes
of water at low pressure is highly effective in removing
surface contamination and is readily available to any fire department.
Recommendation.
For decontamination to be effective for saving lives from rapid actingagents such as GB (sarin) nerve agent, it must be instituted within minutes of exposure.
Responders are expected to be able to perform such decontamination only if they arealready on the scene when the agent is dispersed. Such instances could include an advance
warning of a chemical device, prestaged apparatus/responder at a credible threat location,
and backup response element to a tactical takedown of a suspected chemical terrorist or
laboratory facility. Outside of immediate response and lifesaving, decontamination is alsonecessary for more persistent agents such as VX nerve and mustard agents, to prevent
cross-contamination between casualties and with rescue personnel and healthcare
providers.
The CWIRP
Guidelines for Mass Casualty Decontamination During a Terrorist ChemicalAgent Incident
report outlines several approaches to the establishment of decontaminationsystems. Departments should carefully evaluate the types
of systems outlined in the report and evaluate what levels of
decontamination they can accomplish based on theirresources. Additional equipment may be procured for mass
decontamination operations through the federal grantprocess. Mass-casualty decontamination must then beincorporated into the department's normal training
program.
Studies into the effectiveness of decontamination withwater have looked at two aspects of the decontaminationprocess: the volume of water required and the time a
Disrobing provides approx-imately 80 percent of agent
removal during decontam-
ination.
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victim should remain in the shower to effectively flush an agent from the skin. Preliminary
results indicate that a large volume of water is necessary to adequately flush agent
simulants from the skin. This represents the type of water flow that is provided with fire
hoses at a low-pressure setting. Lesser volumes of water, such as that provided by a garden
hose or mist sprayer only wet the victim's skin and do little to actually remove the agent.
The CWIRP continues to work on further issues involving mass-casualty decontamination.These issues include the following:
*
Other means of decontamination to include dry decontaminants.*
Cold weather decontamination.Issue: Equipment Resources
The response to a chemical WMD incident is expected to be both manpower and resource
intensive. A community's level of support can rapidly be overwhelmed. The additional
threat of equipment contamination and the requirement to take such equipment out of
service for a prolonged period of time can further inhibit the ability to provide normal
service to the area. Additional, specialized equipment will also be needed as part of the
chemical response.
Recommendation.
The Emergency Response Functional Group agreed that the more
resources available to the Incident Commander (IC) the better the response to any overall
emergency operation could be performed.
Limited stocks of specialized chemical response equipment may be stored on individual
apparatus. Backup supplies should be immediately available from in-house stocks and a
local network of suppliers and manufactures. Communities should identify what special-
ized equipment is available regionally to identify military-specific chemical agents. Most
HazMat teams have similar types of commercial agent detectors, but they may have limited
or no military agent detection capabilities. Every HazMat team should have the basic
chemical agent detectors (e.g., M8, M9 paper). These are the simplest form of detectors
that any team can use to gain some possible indication of a chemical warfare agent. Other
types of detectors such as colorimetric tubes are available and can easily be stored and used
by a local HazMat team. Identifying and equipping a regional response asset with
enhanced detection equipment for suspected military agents increases the local commu-
nity's ability to provide a more accurate agent identification prior to the arrival of state or
federal resources.
To further deal with the immediate needs during a response, jurisdictions should reevaluate
their mutual-aid agreements to determine if any adjustments need to be made in the case of
a chemical WMD incident. A list of specialized equipment available in the surrounding
areas that may be needed for a chemical response should be established and updated as
needed. A method of rapidly determining the serviceability of such equipment should also
be developed. Prestaging of such resources may be accomplished in preparation for a
special event or in the event of any increased threat of chemical terrorism in an area. To be
effective, these types of lists must be readily available to the IC.
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A list of suppliers, dealers, and manufactures of fire, EMS, rescue, and HazMat equipment
and emergency vehicles is beneficial when equipment or apparatus are declared nonservice-
able. This will reduce the time necessary to locate, order, and replace the required equipment
or vehicles. In addition, a manpower resource list including department, agency, local, state,
and federal names to contact for assistance in expediting emergency requisitions.
Issue: Accountability and Identification
A key component of the Incident Command System (ICS) is the need for accountability.
Accountability of emergency personnel, equipment, and apparatus and the identification of
victims and personal property are essential. Each sector, as part of its area of operations,
should establish some form of accountability and provide the command post (CP) regular
status updates. These status reports will permit the CP to quickly gain information and
enable the IC to evaluate the overall resources and make any adjustments necessary to
control the incident.
Recommendation.
In preparing for any incident, it is suggested that all fire, rescue,
HazMat, and EMS personnel understand the importance of accountability and to have in
place good methods of identification. One method of personnel accountability widely used
throughout the fire service is the Personal Accountability Tag (PAT). It is suggested that
other response agencies incorporate some form of personnel accountability into their
standard practice.
Response agencies should have and maintain supplies for the identification of victims and
personal property. A form of bar-coded or sequentially numbered triage tags with peel-
and-stick labels is recommended for tagging bags of personal property and other reports so
that they can easily be identified without recording each casualty's pertinent information
(e.g., name and address) each time.
Law Enforcement
Issue: Pre-Incident Intelligence Sharing
Intelligence information is one of the most important aspects of law enforcement
operations to prevent criminal and terrorist events. Information gathering and tracking ofindividuals suspected of possible criminal intent are key to providing a safer community
for our citizens to live in. To provide a complete understanding of the threat, a close infor-
mation-sharing network should be established between local and state law enforcement
jurisdictions.
Recommendation.
Law enforcement agencies should designate one or more investigators
or officers within their intelligence unit to focus on threats of terrorism. One individual in
this network should be responsible for disseminating information to other agencies that are
affected. This person should be on the notification lists of private (including defense
contractors and C/B research facilities) and public organizations (including fire
departments, hospitals, public health, public alerting systems) who may obtain information
concerning problems or suspicious circumstances that are relevant to law enforcement
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The M17 series mask
was phased out of
military use beginning
in 1991.
intelligence. It is further recommended that regular intelligence reports be disseminated to
the field to keep personnel and commanders informed of trends, symbols, and officer safety
information.
A regional intelligence network on terrorism consisting of federal, state, and local law
enforcement is recommended. This regional network will keep all levels of law
enforcement informed of potential threats or trends that might cross jurisdictional
boundaries. Neighboring states should establish an additional network for sharing similar
information on trends or threats. In most cases, the likely point of contact (POC) should
come from the state police intelligence unit who should act as the conduit between local,
state, and federal agencies.
Law enforcement agencies must also consider what, if any, intelligence information can be
shared outside of the law enforcement community. If intelligence indicates that an
imminent threat exists, pre-notification to response units could aid in the overall response
and safety of responders. The sharing of intelligence outside of law enforcement agencies
is strictly at the discretion of law enforcement.
Issue: Personal Protective Equipment for Law Enforcement Officers
PPE for officers was a topic of much debate and discussion
among the program's participants and organizations. Police
officers have experience with respiratory protection through
their use of gas masks for riot control. The threat of
chemical terrorism however, clearly opens up previously
unexplored protection requirements for law enforcement.
Occupational Safety and Health Administration (OSHA)
respiratory requirements have been mostly overlooked when
dealing with riot control masks. Results of this can lead to
an improperly fitted mask or a poorly trained officer. In a
riot control situation this may pose an inconvenience only to
the responding officer; however, the same problem could result in death in a chemical
incident response. OSHA Regulations (Standards29 Code of Federal Regulations [CFR])
1910.134 define requirements for respiratory protection; however, there are no OSHA
standards for Chemical Warfare Agents for civilian respirators.
Many departments possess and use M17-style military surplus masks for
their riot control protection primarily because they can be obtained at
minimal or no cost. These masks are old, replacement parts are hard to
find, and many are unserviceable. Testing a selection of masks used by
several departments validated these points. The program conducted two
tests on the M17 masks that several departments currently were using for
riot control purposes.
The first test focused on the serviceability of the masks according to
military serviceability standards for chemical warfare agent (CWA)
protection. Test findings indicated that masks did not have CWA filters
Mask fit requirements present a major
challenge to departments; however
compliance is essential to officer
safety.
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Affordable, quality protection was the
goal of the CWIRP law enforcement PPE
study.
in them (two of the three filters developed for these masks were for riot control agents
only), were dry rotted, and/or had unserviceable components. Even after the masks were
rebuilt with serviceable components, one-third of them failed to achieve a seal on the test
and evaluation machine.
The second test involved evaluating the fit of the mask to the officers based on the OSHA
1910.134 fit test requirements. Officers were issued masks according to department
procedure and donned them based on their current level of training. Even after assistance
in properly donning the masks, almost half of the participants were unable to achieve a
proper seal to National Institute of Occupational Safety and Health (NIOSH) standards.
The Law Enforcement Functional Group started their investigation of overall officer PPE
with two factors in mind:
1. Recommending levels of protection based on the expected role of the officer in
responding to a WMD incident.
2. Identifying protective equipment that is affordable, easy to maintain, and capable of
withstanding the rigors placed on it by the officers.
Recommendation.
PPE was recommended based on the following:
1. The roles of law enforcement in the chemical incident response.
2. The likelihood of contamination in each of these roles.
The basic patrol officer is expected to operate primarily on the
outer perimeter of the contaminated area and should encounter
little or no contamination. However, because cross-
contamination from victims, wind shifts, and secondary agent
releases could further spread the contaminant, protection is
essential. Patrol officers may also be called upon to perform
limited duties in support of decontamination operations on theouter limits of the warm zone.
Testing was conducted using five protective suits and one
officer in standard duty uniform. The ensembles also con-
sisted of a negative-pressure respirator (MCU2P), butyl rubber gloves, and butyl rubber
boots. Officers performed motions and functions that they would expect to conduct while
operating on the perimeter of a chemical incident (directing traffic and crowd control).
Protection afforded from the suits ranged from 17 to 42 times that of an unprotected test
subject.
Operations in areas of increased agent concentration require better protective equipment
and rely on increased awareness and safe operating procedures to ensure protection of
officers. Because of this, specially trained teams are recommended for these missions.
The primary recommendation was for Special Weapons and Tactics (SWAT) teams and
other specialized teams to fulfill this role since they are already familiar with enhanced
training, equipment, and tactics.
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SBCCOM, with the cooperation of Maryland State Police Special Tactical Assault Team
Element (STATE), conducted a series of tests on several protective ensembles for the basic
patrol officer. The results of these tests and a more detailed discussion of PPE issues for
law enforcement are documented in a report entitled
Personal Protective Equipment
Guidelines for Use by Law Enforcement Officers at a Terrorist Chemical Agent Incident.
This report when finalized will be available on the SBCCOM Web site
www2.sbccom.army.mil/hld.
Issue: SWAT Tactics and Protective Equipment
Exercises conducted by the IRP and the 120-city training program have brought attention
to issues that may require the conduct of tactical law enforcement operations inside of a
contaminated area. Such operations may consist of operating in an area where chemical
agents have already been released, or where the potential for release is high, i.e. suspected
production laboratory (cookhouse) or dignitary protection.
Clothing worn by tactical officers must meet the needs of the mission and be compatible
with specialized equipment and tactics. Tactical operations require stealth, a high degree
of dexterity, and unencumbered movement. Additionally, the specialized tactical
equipment and techniques used by officers can easily tear clothing that is not designed to
withstand the rigors of such operations.
Inherently all chemical protective ensembles are cumbersome and hinder communications,
dexterity and vision. Many commercial types of protective ensembles however clearly do
not lend themselves to tactical operations due to their visibility (bright colors), noisiness of
the fabric, and short duration of operation from limited bottled air supplies.
Recommendation
. Operating in a contaminated environment requires specific training
and knowledge on protective equipment and procedures. As such, it is recommended that
departments train members of each of their tactical teams to the HazMat technician level.
This is similar to training team members to be "tactical medics". This training would give
each team the ability to perform operations such as detection and sampling in conjunction
with their tactical mission as the situation and time permits. This can aid in reducing the
time necessary to determine the specific agent involved and the extent of contamination.
This would also give each team a more definitive understanding of the decontaminationprocess as it pertains to chemical contamination.
Charcoal impregnated or lined protective suits or chemical protective undergarments are best suited
to the tactical officer and their operations. The types of chemical protective ensembles depicted
include left-Level C charcoal impregnated overgarment, center-Level A, and right-Level B
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In order to meet the challenges of tactical operations the CWIRP chose to evaluate several
styles and types of charcoal lined/impregnated protective suits and chemical protective
undergarments for tactical officers. These types of suits are highly durable, provide very
good chemical protection and meet the needs of the tactical officer well. They include
chemical protective suits currently in use by the U.S. military and similar types. Unlike
suits recommended for patrol officers, the charcoal style suites afford a greater degree of
durability to tactical operations such as crouching, repelling, and climbing.
Basic OSHA safety requirements indicate that Level A protection (fully encapsulated suit
with self-contained breathing apparatus) is required when an unknown agent or
concentration is present. If there are any threats of suspects or additional
explosive/chemical devices being in the incident area, HazMat teams are expected to refuse
to enter the area until it is cleared by law enforcement. Therefore it is expected that the
agent and concentration will not be known and that victim signs and symptoms will be the
only indicator of the hazards.
Level A and Level B protection (both requiring SCBA respiratory protection) do not
support tactical law enforcement operations. Suits used with Level A and B protection are
noisy and generally bright in color, also not lending to stealth operations. While these
types of suits can be special ordered from most manufacturers in any color specified, this
would not eliminate the noise issue. In addition, the fabric of these suits tear easily and is
not expected to withstand even the simplest of tactical maneuvers. SCBA provides for a
limited operation based on the air supply whereby officers may be required to disengage
from their mission against standard procedures. This is particularly true during stealth
operations or when confronting a suspect. Level A protection also does not lend to firing
shoulder fired weapons.
SBCCOM, in conjunction with the Maryland State Police, is conducting testing on
protective ensembles (equivalent to Level C protection) for SWAT teams. This testing is
similar to the procedures done for ensembles for patrol officers on the perimeter of an
incident. The ensembles being testing include a negative-pressure respirator, butyl rubber
gloves and either a charcoal lined/impregnated suit or chemical protective undergarments.
The chemical undergarments are worn under the SWAT officers' uniform. Chemical suits
are of the military style and include those currently in use by the military as well as others
that have been developed for several law enforcement agencies. These style suits provide a
better fit with the tactical mission and equipment.
The tests evaluate the ensembles based on the chemical agent protection provided as well
as compatibility with the teams equipment and tactics. Results of the testing will be
published in an overall law enforcement PPE report and be available on the SBCCOM Web
site at www2.sbccom.army.mil/hld when testing is completed.
Issue: Bomb Squad Tactics and Protective Equipment
Bomb technicians face critical challenges of both agent and explosive hazards when
confronted with conventional improvised explosive devices (IED) inside of a contaminated
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area or with chemical IEDs. The requirement to search for and possibly dispose of
chemical and/or conventional IEDs is expected to accompany any chemical WMD
incident. Most bomb technicians are not trained or equipped to operate in a chemically
contaminated environment. Standard bomb suits do not provide for any form of chemical
protection and already present the wearer with high danger of heat related injury.
Recommendation:
As with the recommendation for tactical teams, it is recommended that
bomb technicians be trained to the HazMat technician level
There are few chemical/biological (C/B) bomb suits available on the market. These suits
are relatively expensive and while providing chemical agent protection in the form of
wearing a chemical protective suit and respirator under the suit, afford only approximately
70 percent of the standard blast protection of a standard suit. Recommendations from the
manufacturers of these suits also indicate that the filters of a negative-pressure respirator
used in conjunction with a C/B bomb suit are subject to damage from a detonation that can
render the filters unserviceable. As such, SCBA is their recommendation for respiratory
protection.
This type of ensemble presents various limitations for the technician. SCBA limits the time
on target for conducting evaluations and render safe procedures to the limits of the air
supply. This can call for a rotation of technicians in dealing with a device. Additionally,
the suit, with chemical protection worn underneath presents an elevated level of heat
buildup above that normally associated with the standard bomb suit.
Technicians should be well trained and experienced in the wear, use and additional
restrictions of a C/B bomb suit and operating in a contaminated environment.
Issue: Enhanced WMD Training
Throughout the discussions of the Law Enforcement Functional Group, it became evident
that additional training above the basic DPP awareness and operations level training is
important to overall officer safety. A list of the performance requirements associated with
the DPP training is included in Part VIII of this document. A basic part of any training
should also be the awareness of the roles and responsibilities of the other department
disciplines.
Recommendation.
The functional group considered the types of missions that officers
may be required to perform in response to a chemical WMD incident and recommended
additional training areas that should be considered. These recommendations are designed
to build on the training of the basic WMD Awareness and Operations courses of the DPP
Train-the-Trainer course. Jurisdictions that are not scheduled to receive this training
should make every effort to obtain the materials from the nearest city that has been trained
or state Emergency Management Agency.
Training officers on the proper use and maintenance of any equipment issued for a WMD
response is vital. If officers are not properly trained in their protective equipment or it is
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Aviation assets provide a means of
rapidly delivering critical response
teams and equipment to a region
involved in a chemical terrorist
incident.
poorly maintained, they could have a false sense of security in the protection afforded
them. Poor training or improperly maintained equipment can lead to serious injury and/or
the loss of lives.
The list of additional training recommendations is included in Part VIII of the Playbook.
The group based their recommendations solely on the enhanced training necessary to
perform the perceived missions. Time, resources, and funds were not used as limiting
factors in the development of the list. Departments must evaluate the recommendations
and their available training time and funds when determining what training to conduct for
their officers; however, officers who are not properly equipped and trained should not
attempt to perform such missions. They should prioritize training according to their current
level of awareness. Additionally, elements within a department should be prioritized for
training based on the likelihood of being involved in the response.
Issue: Use of Aviation Assets
Operation of aviation equipment by any agency is expected to be prohibited in or near a
contaminated area. Medevac helicopters will probably not even fly decontaminated
patients because of the potential threat of contaminating the aircraft or pilot. However,
aviation assets are a valuable resource to the rapid response during an incident and the
program addressed several issues on how they could be more appropriately used during a
chemical terrorist event.
Recommendation.
Police aviation assets provide ideal rapid
transportation means to move specialized teams (e.g., bomb
squad and SWAT) and/or equipment to the vicinity of the
incident site. Ground transportation will be necessary to
deliver equipment from the aviation landing zone to the actual
site, but aviation provides a quicker means of supplying
needed assets close to the incident. Medical facilities closest
to the incident site will most likely be rapidly overwhelmed
and will quickly run out of necessary medical resources (e.g.,
ventilators). Strategic movement of key medical personnel,
equipment, and antidotes to a location close to the incident site or medical treatment
facilities can be best accomplished by using aviation assets.
The need to provide rapid analysis of a known or suspected agent provides another avenue
for aviation support. This is particularly true where the agent has not yet been dissemi-
nated and containers of the suspected agent are taken into custody. Coordination to
analyze the agent should be done in conjunction with the FBI; however, local aviation may
be asked to transport the substance. Law enforcement agencies should check with their
local FBI office and state police departments to ascertain how movement of known or
suspected chemical agents can be accomplished. Clearance to use local aviation assets
should be outlined in a memorandum of understanding (MOU). Local jurisdictions should
also check with their aviation insurance agency prior to signing an MOU.
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Mark I Nerve Agent Antidote Kit
Issue: Antidote Kits
The only military chemical warfare agents with a specific
antidote kit are the nerve agent series. Autoinjectors of
atropine and 2-PAM chloride make up the components of
the MARK I Nerve Agent Antidote Kit. These kits are a
controlled medical item, have a limited shelf life and strict
security and storage requirements, and can only be
administered by certain levels of medical personnel. To be
useful to anyone exposed to a lethal dose of nerve agent,
they must be administered within seconds to minutes after
exposure.
Recommendation
. The stringent requirements of the MARK I antidote kits make them
improbable to be issued to each police officer on a permanent basis. The best protection
officers have is rapid identification of the hazard through visual observation, distance from
the source of contamination, and appropriate protective equipment. Officers who receive a
nonlethal dose of agent should be removed from the source of contamination and be
attended by medical personnel as soon as possible.
Police departments may consider stocking antidote for specialized teams such as SWAT
teams through agreements with local medical organizations that are maintaining these
items for a community medical response. These specialized teams can then be outfitted
with antidote prior to a mission where nerve agents have been released or are suspected.
Departments should also check into the possibility of gaining a waiver for such operations
that would allow officers to administer antidotes.
In any situation where antidotes are or may be provided to law enforcement officers, proper
training and precautions must be conducted.
Health and Safety
Issue: EMS Personnel Administering Antidote Treatment not within Their
Scope of Practice
In a chemical weapons (CW) incident the prevailing concern is to carry out a system of
care that provides the greatest good for the greatest number of
patients. Early decontamination, early treatment, and quickaccess to definitive care will greatly increase the number of
survivors. Health concerns are greatly reduced when victims
receive antidotes at the earliest possible moment.
The constraint, however, is that the scope of practice for
Emergency Medical Technicians-Basic (EMT-B) and EMT-
Paramedics (P) generally does not allow for the administration
of antidotes. Departmental, regional, or state governing
bodies do not include protocols that address exposure to
Local jurisdictions need to address
protocols for emergency medical
practitioners to administer antidotes.
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chemical WMD. At best, these protocols may only specify certain instances or extreme
circumstances where providers may act outside their scope of practice. Examples of this
include failure to establish radio communication with medical command, lengthy transport
time, that the provider has been trained on the procedure, or if failure to act would result in
certain patient death.
Recommendation.
The National Highway Traffic Safety Administration (NHTSA) and
EMS governing bodies including the National Registry of EMT should develop protocols
that address the treatment of patients who suffer CW exposure.
Medical directors for the local EMS system and public health agency should review the
principles of rendering care to the CW victim, (i.e., decontamination then treatment), aswell as the specific antidote needed for different types of chemical weapons: what is
administered, how much, how is it administered, contraindications, and constraints to
administration.
The medical director needs to oversee the treatment of multiple patients, specifically the
administration of antidotes at the scene.
When medical direction is not available at the scene, jurisdictions should work out a plan
that encompasses rendering CW antidote treatment at the scene, either by a predesignated
Metropolitan Medical Response Team (MMRT), Go-Team, or similar responding unit.
Issue: Stockpiles of Antidote and Equipment to Include Distribution Plan
Often the number of patients requiring treatment outweighs the medical supplies for a CW
event. CW-specific medications like atropine, pralidoximechloride (2-PAM CHLORIDE),
diazepam, methlyprednisone, British Anti-Lewisite, bronchodialators, IV fluids, cyanide
kits, or equipment such as respiratory support devices may not be stocked in a large enough
quantity or at all by smaller jurisdictions.
Stockpiling medical supplies also requires specific planning. All drugs have an expiration
date, thereby requiring the stock to be rotated to avoid unnecessary disposal. Medical
equipment must pass regular biomedical inspections as well as be replaced when models
become too antiquated.
Stockpiling CW medication and supplies raises the questions of who is responsible for the
maintenance of the medication and equipment, where the stockpile should be located, and
who will pay for it because the cost of maintaining such resources may be beyond the
capability of many jurisdictions.
Furthermore, once a stockpile is in effect, how it is distributed throughout a jurisdiction and
subsequently brought to the incident site must be resolved.
Recommendation.
The health department should assist area hospitals and jurisdictions in
designing their antidote treatment stockpiles and medical equipment in preparation of a
CW attack. The health department should maintain a central database of resources collated
by hospital or jurisdiction, that specifies the types and quantities of antidotes and medical
equipment available. A comprehensive plan requires input from EMS, hospitals, and the
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Alternative care facilities, established
in schools or similar structures, allow
existing medical treatment facilities to
focus on critical care patients.
health department to provide a coordinated medical response to the community. MOUs
should be developed between these organizations to outline stockpile and distribution
procedures and responsibilities.
Each jurisdiction should address a pharmaceutical product list, medical equipment list, and
storage locations for the items specific to that of a CW event. An example of this type of
list is the Seattle, WA, MMRT pharmaceutical product list that includes ciprofloxacin,
5 percent dextrose in water, albuterol, atropine 2-PAM Chloride autoinjection kit (MARK I
kits), atropine preloads, diazapam, methylprednisone, aminophyline, cyanide antidote kits,
and potassium iodide.
Multiple stockpile locations should be established because any area is subject to a terrorist
attack. If the stockpile is only in one location and that area should become gridlocked
secondary to the attack, supplies will not be accessible. Location of the stockpile should be
easily accessible for fire department and EMS personnel or any personnel who retrieve the
resources.
The health department's role is to facilitate the distribution of needed antidote treatment
and medical equipment in a disaster. Patients will not evenly distribute themselves as they
enter the healthcare system. Often one or two hospitals will become the primary site for
treatment, thereby requiring more antidote and equipment than originally stocked. The
health department should facilitate redirecting stockpiles to hospitals or off-site treatment
centers administering to the CW victims.
An MOU is needed with the agency responsible for delivering the stockpile to the incident
site's treatment location. Agencies that can be used include fire departments, EMS
agencies, mass transit organizations, taxi cab services, public works, private ambulance
services, and helicopter transport. Redundancy plans should be made because many
agencies may be unable to deliver stockpile items.
Issue: Predetermination of Off-Site Casualty Relocation Centers
A CW terrorist attack can produce an enormous number of
casualties that can overload a community's healthcare
system. Not all chemical agents are quick acting or result in
immediate casualties or fatalities. It is anticipated that some
victims will leave the scene contaminated and attempt to seek
medical care on their own. They will turn up at their private
doctors' offices, managed care organizations, and local
emergency departments (EDs). They have the potential to
contaminate their own homes, the local population, and
anything they might encounter after an incident exposure.
Most hospitals will not be able to manage the vast number of
victims from a CW incident and, more importantly, they will
not be able to decontaminate victims as they arrive. To effectively manage the health and
safety of a large number of patients, the public health department will need to institute
temporary off-site treatment centers that can provide immediate access to definitive care.
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These centers are referred throughout this document as the Off-Site Triage, Treatment, and
Transport Center (OST
3
C).
Recommendation.
The Emergency Operations Plan (EOP) should identify public
buildings that can be temporarily converted to an OST
3
C. In most community evacuation
plans, schools or armories are used to house civilians in the event of a natural disaster.
This plan also endorses the use of schools because they support the requirements of an
OST
3
C better than most public buildings. The health department or other governing body
responsible for operation of the OST
3
C will need to establish a written MOU with school
superintendents and other support agencies essential to its operation. Provisions for
dismissal of students, building security, and opening of the facility during nonschool hours
should be predetermined and outlined in the OST
3
C response plan.
It is possible that a building may not be able to be fully decontaminated after it has been
used as an OST
3
C; therefore, it is recommended that the health department select older
facilities when choosing a site, in the event that the structure needs to be torn down and
rebuilt.
The facility will need to house and care for a large number of victims. It needs to have
water, restrooms, food provisions, furniture, electricity, and heating. Schools contain the
needed human services to maintain and sustain patients because they already have
amenities such as chairs, desks, cafeterias, water fountains, auditoriums, bathrooms, and a
nurse's office with beds, chalkboards for information tracking, and public announcement(PA) systems and televisions.
High schools or middle schools should be used before elementary schools. Both high
schools and middle schools have larger gymnasiums, locker rooms, separate shower
facilities, and large athletic fields; most elementary schools do not have these facilities.
Another important reason in choosing a high school is that teenagers are able to take care
of themselves if the school needs to be dismissed midday. Additionally, most parents
would be more hesitant to send their children back to an elementary school that was
potentially contaminated than would parents of older children.
Issue: Medical Emergency Operations Plan
Many cities or jurisdictions do not have a comprehensive EOP that addresses a chemical
WMD event. A CW event demands the management of multiple resources in a timely
manner to a greater degree than most communities are familiar with. The lack of such a
specific plan will lead to confusion regarding how a city can implement medical command
and control for a mass number of patients. There is a great potential to overtax the medical
community's local, regional, and state resources.
Recommendation.
Cities can easily supplement existing EOPs with a chemical WMD
annex (Atlanta, GA's Metropolitan Medical Response System [MMRS] Plan is a good
example, Health and Human Services, 1997). The written plan should provide a template
that community leaders can organize and execute quickly, that specifies the medical
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response at strategic locations, and that addresses the level of care commensurate with
available resources.
The annex should address hospital preparedness to a CW event since scene victims and the
"worried well" will try to enter community EDs, and will likely contaminate medical
resources. Patients from a CW event will require decontamination prior to treatment andparticular medications. In most systems, hospitals are not accustomed to enacting their
own Incident Command System (ICS) to control this large influx of contaminated patients.
Information pertaining to establishing a hospital ICS can be found in the Hospital
Emergency ICS (HEICS) manual.
The annex should also address the health department's role in a CW event, since the larger
population may be affected by contaminated animal carcasses, delay in routine medical
care (e.g., dialysis), victims who may inadvertently contaminate family members, large
numbers of deceased, and those psychologically hampered by the event. An off-site
treatment center can be used to provide command and control over public health concerns.
A thorough description of the OST
3
C is being published in the
Concept of Operations for
the Off-Site Triage, Treatment, and Transportation Center (OST
3
C ).
This document, when
completed will be available at the SBCCOM Web site: www2.sbccom.army.mil/hld).
The annex should also include the local or regional poison control center (PCC). This
24-hour service could provide specific first line information about a CW substance or may
help in the general identification of a CW agent. Identification is the key to successful
decontamination, treatment, and containment. Making PCCs part of the solution includesbecoming part of the communication link that would provide information to call-in
patients, primary care physicians, and hospital EDs. Information provided should focus on
the location of an OST
3
C and hospitals open for patient referrals as well as proactively
faxing local area hospitals the CW agent characteristics, exposure signs and symptoms,
latent effects, and treatment protocols.
Issue: Emergency Notifications throughout Medical Community
A major CW incident will rapidly overwhelm a community's medical system. The Tokyo,
Japan, subway attack in 1995, which used a low-quality sarin and was poorly disseminated,
resulted in more than 5,000 people seeking medical care.
When a CW incident occurs, the larger medical community is unaware of the event and its
need to respond and prepare. Medical staff schedules will change to a 12-hour shift
requirement, staff may need to be called back to their place of employment, and other
medical providers must be contacted to relieve the present staff. Other agencies, including
the local health department, primary care physicians, local clinics, nursing homes, and
surrounding EDs must be notified of a CW incident to avoid spreading the contaminant.
Recommendation.
The local health department should develop a notification process to
include the aforementioned medical sites. If there is no central notification center in place
(e.g., the Emergency Medical Response Communications [EMRC] center in Maryland), then
one governing body should be notified by the IC from the scene that a CW incident has
occurred. In turn, they should notify via telephone or radio all the other healthcare parties. A
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notification protocol should include calling these groups as well as faxing them information
pertaining to the chemical agent. Faxed information should address the type of agent, need
to limit access to the site, need for decontamination, need for medical personnel to wearprotective clothing, patient signs and symptoms, and treatment recommendations.
Preestablished chemical reference notebooks should be developed and on hand at all
medical treatment facilities to enhance agent recognition and treatment procedures in
response to a chemical WMD incident.
Issue: Patient TrackingThere is a great need for patient tracking. As evidenced in the Oklahoma City bombingincident and other mass-casualty incidents (MCI) (e.g., recent aircraft crashes), there is a
great demand for information concerning citizens who may have been affected by the
incident. The identification of victims and deceased, location of patients, and notifications
to family members are massive undertakings of the medical and local communities.
Additionally, the fact that a crime has been committed makes identification of all persons
at the scene necessary for the law enforcement investigation.
Patient identification and tracking must begin immediately. EMS must track patients asthey are triaged, decontaminated, treated, and transported from the scene. Patients will be
separated from their belongings as well as other family members as they are processed
through the decontamination and medical system. Relatives from across the nation willseek information on family members whom they believe were at the location of the attack.
Hospitals also need to keep track of those patients who enter the medical system who were
a part of the CW event. These patients may or may not enter the system by EMS, whereby
patients would be tracked via a field triage tag. Having a database that supports the care
rendered helps with many other facets of the CW event, without duplicating patient
tracking mechanisms.In a CW event not only do patient belongings become part of the criminal investigation, but
medical treatment, specimen results, and patient outcomes are important factors to
investigators. Additionally, suspects may be among the victims treated by the medical
system. This further increases the importance of collecting and tracking information oneveryone from the incident.
Recommendation.
The initial contact and first attempt at identifying and tracking patientswill occur inside the hazard area by fire and EMS. In the interest of providing immediate
decontamination to casualties known or suspected of being contaminated, any means ofwritten identification and tracking is too time consuming. It is possible that some citizensmay slip through the medical system after undergoing decontamination by seeking aid ontheir own or refusing assistance. The importance for law enforcement to identify and
interview everyone from the scene makes this additional attempt at identification essential.
A unified means of collecting patient information from the scene, hospitals, and off-site
treatment centers is recommended.
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Hospitals need to be prepared to execute
mass-casualty decontamination with theirinternal assets.
Many EMS systems are currently using the MET TAG triage tag. In the interest of time,
basic information such as name, date of birth, chief complaint, and destination, should be
recorded on a color-coded triage tag. The tag itself should be waterproof, since water-
based decontamination will break down this method of patient tracking. The tag should
have several bar-coded stickers that could be easily placed on bags of patient belongings,
destination rosters, and hospital charts. Off-site treatment centers and hospital EDs should
also use the same system, since linking the mass numbers of patients from the event is
necessary.
The triage tag method should be supplemented by an uniformed means of patient charting
that is used by hospital ED and off-site treatment centers. Data collection should be simple
and basic because medical, volunteer, or administrative personnel would not be familiar
with the forms. Additionally, the form should have a bubble-scanning sheet attached to aid
the downloading of data at a later time.
Because the CW event will be an ongoing criminal investigation, the list of victims should
be maintained separately from normal records.
Issue: Hospital Decontamination Area/PlansIt is expected that any CW terrorist attack will involve multiple victims, many who will
flee the scene without being decontaminated. Hospital ED are generally not suited for
mass decontamination of patients because the Joint Com-mission Association of Hospital Organizations (JCAHO)
does not require a specific area, but only a means of decon-
taminating single patients. Hospitals rely heavily upon the
fire department to assist with patient decontamination;however, during a CW event, these resources will be
dedicated to the incident site and may not be available.
Presently, most hospitals generally do not have a decon-
tamination area or PPE to prevent cross-contamination or
the experience to perform mass-casualty decontamination.Recommendation.
Hospitals need a written decontamination plan as part of their in-housedisaster response. This could be an annex to their current emergency preparedness plan.
This annex should follow National Fire Protection Association (NFPA) 471 and 472
recommendations as well as uphold OSHA 1910.120 decontamination standards. Hospitaladministrators could use
Managing Hazardous Material Incident Medical Management
Guidelines for Acute Chemical Exposures
when writing their response plan (HHS, 1991).
Hospitals that may not be able to supply a permanent decontamination area should lookinto procuring a portable decontamination unit. The portable decontamination unit could
be as simple as a fire hose connected to a fire hydrant. It is important to note that a garden
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Hospitals should have at least Level C PPE for their ED staff to perform patient
decontamination.Hospital EDs can also establish an MOU with fire departments from outside their com-
munity to assist with the decontamination of patients in the event of a CW incident.However, these resources may also be involved in the response to the incident site and,
therefore, not be available. Essentially, there is no reliable substitution for a hospital
having its own stand-alone decontamination system.In response to the growing concern for HazMat and chemical WMD, JCAHO should
consider updating its HazMat requirements by mandating hospitals to maintain a decon-
tamination area that can service multiple patients as well as mandating a management of
CW casualties training course as part of the hospital employees' annual training.
Issue: Hospital Training on Triage Protocols
Hospital EDs are the number one patient entry point. In light of a CW event, triage and
treatment of a multitude of patients differ from that of routine triage. Though hospitals are
required by JCAHO to practice internal disaster drills, they are not encouraged to use the
EMS system of triage. Linking hospital EDs to the EMS system allows for continuity of
triage practice and patient tracking that is necessary for a CW event.Recommendation.
Hospitals should provide a CW exposure module as part of their
annual training. This module should focus on the priority of decontaminating prior to
patient treatment, wearing PPE by hospital staff members, using the EMS method of triage
(Simple Triage and Rapid Treatment [START] medical triage system), triage tags (MET
TAG), patient and equipment tracking, and the medical management of chemicallyexposed patients. Training should be extended to hospital administrators as well. CW
patient care should fit into preexisting internal disaster plans and be practiced as part of the
JCAHO biannual drill.
Training should also emphasize the large number of worried well that will report for
medical evaluation and treatment following such an incident.
Issue: Hospital Resupply
In a CW event, the need for antidote medication and medical equipment supersedes that of
supply. Since a multitude of patients demand similar treatment modalities, medications
such as atropine, 2-PAM chloride, British Anti-Lewisite, and cyanide kits will quickly
become depleted. Medical equipment, including nebulizers, ventilators, cardiac monitors,
stretchers, and beds, will also become exhausted.
Hospitals today practice "just in time" delivery as a means to cut inventory costs. This
practice demands a strong reliance on area distributors. In a disaster situation, distributor
stock will deplete quickly since all area hospitals maintain the same practice and rely on
the same local distributors.
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Medical examiners will need train-
ing and equipment to conduct
investigations with the FBI on a
chemical terrorist incident.
As part of cost saving measures, hospitals are not inclined to financially support the
stockpiling of equipment and medications. Medications need to be rotated to avoid
expiration. Additionally, equipment needs to be updated through hospital biomedical
departments as well as be replaced when older models become antiquated.
Recommendation.
Each hospital should plan to have its own stockpile that is specific to
items needed to treat victims from a CW event. Hospitals can add these items to their
central supply department and their backup warehouse. Another backup plan should
include obtaining an MOU from the area distributors for support during times of crisis as
well as MOUs with further outlying and possibly bordering state medical facilities.
Upon the depletion of stock, the Federal Response Plan's (FRP's) Emergency Response
Plan No. 6 specifies federal aid when jurisdictional and regional supplies are totally con-
sumed. Also, the FRP can be used to supply temporary mass-care facilities with necessary
stock for the treatment of patients in disaster situations. Local plans should be developed
so that they are complemented by federal and state response plans. Hospitals should seek
assistance from the public health department regarding stockpiling and resupply of
chemical antidotes and other essential equipment.
Issue: Medical Examiner Disaster Plans and Resources
The CWIRP recognized the need to address mass-fatality
management because a WMD incident has the potential to kill a
large number of exposed personnel and most jurisdictions are
not prepared to respond to a catastrophic number of fatalities.
The CWIRP formed a specific working group to address the
issues of fatality management that evolved from a series of
workshops focused on scenarios of different proportions based
on a chemical agent incident.
Disaster plans need enough structure to provide staff direction
during a crisis, but also need to be flexible enough to grow or
shrink as the situation presents. Often the medical examiner is
unfamiliar with its agency's role in a disaster. This is especially true when the incident is
extremely large and involves aspects that they are unfamiliar with (e.g., contamination).
Medical examiner office personnel should have a clear understanding of their role during a
disaster. Typically three operations must ensue. These are the field operation at the
incident site, establishing and operating a Family Assistance Center/bereavement center,
and handling the daily influx of cases. As the incident size grows larger, outside assistance
must be enlisted to help process the remains.
Recommendation.
Medical examiners are not put in the position of fulfilling an
emergency responder role and, therefore, are not accustomed to performing annual disaster
drills and reviewing their disaster plans. Personnel are not prepared to put plans into
operation, don PPE, evacuate their location, set up temporary off-site operations, or
coordinate activities with an on-scene IC. Because of the catastrophic potential of a
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chemical terrorist attack, preplanning will provide the needed structure to implement an
effective operation.
Disaster plans should include specific supply lists for required functions (e.g., temporary
morgue and temporary autopsy area) so that when a request is made to the Joint Operations
Center (JOC), the request is clear and concise (e.g., specific physical requirements and
disposable supplies).
Disaster plans should address an evaluation team that is capable of entering the hot zone to
assess the situation early. Regional FBI offices are training and equipping their WMD
coordinators to perform operations inside the contaminated area. A joint operation
between the FBI and medical examiner will assist in developing the operational plan for
processing the crime scene and fatalities. This can only be accomplished if the medical
examiner is trained and equipped to perform this role.
Managing chemically contaminated remains requires equipment that the medical examiner
does not use on a daily basis (e.g., PPE, ventilation fans, decontamination supplies,waterproof tracking tags). The jurisdiction should know what other agencies can provideso that the medical examiner does not make requests for state assets that can be provided
locally (the local HazMat team may be able to provide resources to support
decontamination efforts since mass fatality management will likely not be initiated untilafter all live victims have been rescued).
A direct phone line should be established between the Family Assistance
Center/bereavement center, the main medical examiner's office, and the temporary
morgue, if one is established. This direct patch allows medical examiner personnel to
obtain and deliver information quickly and keeps all parties abreast of pertinent
information.
A Family Assistance Center should be established early because it can serve as a central
location for a representative from the medical examiner's office to speak with family
members for identification purposes. Establishing a Family Assistance Center will likely
be a joint endeavor between agencies such as the medical examiner's office, health
department and Red Cross.
Issue: Patient Identification
Law enforcement needs a complete list of personnel who were at the CW terrorist incident.
Many times this cannot be obtained through the EMS triage and transportation lists because
patients flee the scene attempting to enter the healthcare system independently. Under
normal circumstances, when law enforcement agencies attempt to gather information by
requesting patient information from off-site treatment centers, EDs, and mental health
(MH) clinic registries, it is denied on the basis of patient confidentiality.
Recommendation.
Healthcare facilities already gather information needed by law
enforcement agencies. An MOU should be established between law enforcement and the
local health department that allows facilities to share the needed information during a
mass-casualty event that is caused by a suspected criminal act (e.g., CW terrorism).
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Additional information about patients can be gathered by healthcare facilities that would
aid the investigation process, such as name, phone number, location at the incident site, if
they were contaminated and if they witnessed any suspicious behavior.
Emergency Management
Issue: Vulnerability Assessment
Emergency management planning for response to WMD incidents must include an accurate
and realistic assessment of the likelihood of such incidents, the potential targets, and the
resulting impact on the public and infrastructure. Such planning helps maximize the
effectiveness of resources dedicated to consequence management by helping planners'
appropriate training, equipment, and personnel in the right places. Factors to consider for a
vulnerability assessment include the following:
*
An estimate of the probability and characteristics of incidents.
*
An estimate of potential human, property, and business impact.
*
An assessment of the adequacy of emergency response plans.
*
An assessment of the adequacy of personnel training.
*
An assessment of the adequacy of response material resources.
*
An assessment of the availability and response times for outside support.
Recommendation.
Emergency management personnel should ensure that a vulnerability
assessment is a fundamental part of their overall planning for WMD consequence
management. This assessment should be updated on a periodic basis to ensure that
response and emergency plans stay current. Emergency managers should enlist the
involvement of all agencies involved in the emergency response and management of a
CWIRP incident in their planning. Additional information regarding law enforcement
intelligence gathering and assessments is included in the law enforcement sections of this
report.
Issue: Training and Exercise Opportunities
Events such as the Tokyo subway attack, using nerve agent and a plethora of anthrax
hoaxes, have certainly heightened awareness to the potentiality of WMD events occurring
on U.S. soil. This threat, being relatively new, has consequently resulted in training
opportunities offered by many organizations and agencies both in the government sector
from the federal to local levels and in the private sector.
Most notably at the federal level is the DPP sponsored training and exercise program
fostered by the NLD domestic preparedness legislation of 1997. This program targets
selected major metropolitan areas and cities for a training program that features a week of
classroom-oriented training, a chemical tabletop exercise, a chemical functional exercise,
and a biological tabletop exercise.
The range of opportunities varies widely among states and local municipalities. The
National Fire Academy and other such professional training organizations have endeavored
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to incorporate WMD awareness into their respective curricula. Likewise, commercial
enterprises and academic institutions have spawned a number of activities and courses that
address preparedness in the emergency management and responder communities. The
National Domestic Preparedness Consortium conducts training at five locations throughout
the U.S. These include the Center for Domestic Preparedness, Fort McClellan, AL;
Louisiana State University; Texas A&M; the Department of Energy Nevada Test Site; and
the New Mexico Institute of Mining and Technology.
Conferences and symposia are also beginning to directly address WMD consequent and
crisis management issues challenging the law enforcement, medical, emergency response,
and management communities. These forums present an excellent venue for the exchange
of information and updates in the fields concerned with WMD consequences.
Recommendation.
Emergency management and other officials who plan and influence
policies related to WMD consequence and crisis management should actively pursue the
benefits of such training and exercise activities.
Issue: Materials Support
Most materials required for use by first responders and the medical community for WMD
situations are certainly not common items. These include nerve agent antidotes, chemical
protective masks, chemical detectors, decontamination agents, detectors, and anthraxvaccines. Community awareness of the capability and availability of the equipment is
increasing. Questions arise regarding exactly where one might readily find such information.
The Federal Emergency Management Agency (FEMA) Web site is a good starting point.
FEMA's Rapid Response Information System Web page provides information to those
who have access to the Internet. Again, state level support and information sources vary
widely; however, the state level emergency management agency most likely has direct
access to other sources. Mutual-aid support agreements among local jurisdictions should
address availability of WMD-related equipment as part of contingency plans.
An additional resource support might be those assets owned and controlled by nearby
military installations and other federal government organizations. The protocols for acqui-
sition of these assets may be a bit involved but they should not be ruled out as a possible
source of support.
An inventory of local jurisdictional WMD-related equipment should be conducted. This,
along with a WMD vulnerability assessment, should identify material gaps that must be
addressed either with the acquisition at the local level or covered in some fashion through
support from outside sources.
Recommendation.
Emergency management officials should identify assets available at
the local level up to the federal level and prepare contingency plans to incorporate those
elements of support. This should include lists of suppliers, dealers, and manufacturers of
equipment that may be used during a chemical incident response. This information will
reduce the time necessary to locate, order, and obtain equipment consumed or determined
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to be unserviceable. Information regarding funding for equipment is referenced at the
beginning of this section.
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Dispatchers need to be trained to
identify potential chemical inci-
dents and provide direction to
responders to keep them from
becoming casualties.
Part III Initial Response: The First Hour
Rapid response to a chemical terrorist incident is essential to save lives and prevent further
casualties. The initial stages of response are also the most dangerous to the first responder.
Responders rushing to the scene of a chemical attack who are not well informed, prepared,
or properly equipped will most likely become part of the problem and not the solution.
The ability of a jurisdiction to contain and control the extent of damage done by a
chemical terrorist event will be decided within the first hour of the incident.
Lessons learned from the response to the bombing of the Alfred P. Murrah Federal
Building in Oklahoma City indicate the need for rapid control over the response to a
catastrophic event. , Control over the response to this event and accountability of the
responders on scene were not gained until the threat of additional explosive devices caused
evacuation of the area. The impulse to hurriedly rush into an event to save lives without
proper precautions can be deadly to responders. This danger is magnified in the presence
of an invisible, super-toxic, chemical warfare agent.
This section outlines key issues and recommendations that are of immediate concern to a
jurisdiction faced with responding to this type of event. It includes issues relating to the
rescue of victims, responder safety, and operational procedures to prevent contamination of
personnel and facilities involved in the management of the response effort.
"Keep in mind, the same technological advances that have shrunk cell phones to
fit in the palms of our hands can also make weapons of terror easier to conceal
and easier to use."
(President Clinton's State of the Union Address, January 2000)
General
Issue: Dispatch
Dispatch and 9-1-1 operators are the eyes and ears of the
responders until they arrive at an incident scene. The best-
trained and equipped responders can still easily become
casualties during their initial response if they do not have
advance warning of the situation. Standard HazMat
situations preclude knowledge of a known hazardous
substance and involve a limited number of immediate
casualties. A chemical terrorist incident is expected to be
different in that the agent release will be a deliberate
attempt to injure or kill large numbers of victims and the
actual dissemination may go completely unnoticed.
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Operators need to be trained to recognize information that indicates a chemical mass-
casualty event and should be knowledgeable of pertinent information to ask once a
chemical event is suspected.
The dispatch process is not much different for a CW incident than any other request for
service. It starts with the initial caller telephoning the 9-1-1 operator and requesting
emergency help. The caller can be an invaluable resource of information for the emer-
gency responder handling any emergency incident. It becomes imperative for the 9-1-1
operator to ask a standard set of questions, such as the following:
*
What type of emergency you have (e.g., fire, EMS, police).
*
Caller's name.
*
Caller's location.
*
Caller's telephone number.
*
Location of the emergency.
*
What type complex is involved (e.g., house, building, school).
*
Is there a fire or was there an explosion?
*
What type of vehicle, container or device is involved?
*
What type materials or chemicals are involved.
*
Has anything spilled?
*
Do you see smoke or a vapor cloud?
*
Do you hear a bursting or hissing sound?
*
Has anyone complained about an unusual odor?
*
If there are victims and how many.
*
What victims' complaints are.
*
Weather conditions at the scene.
Although dispatchers gather valuable information and
update responders, they are generally not decision makers.
The dispatch center often takes a supportive reactive role by
responding to the requests of the IC during disaster events,
versus disseminating information into intelligence, which is
left to the IC. Thus, initial command and control of a CW
incident should start with the dispatch center, but often are
left to those who respond to the scene. The role of the
dispatch center during a CW incident will become more
prominent as the incident escalates. Like all disasters, the
dispatcher will need to maintain control of multiple radio
transmissions over multiple channels. At this point the dispatch center takes a position of
interpreting information from multiple POCs and relaying that information to the IC.
One major concern is that quite often no standard requirements for emergency dispatch
centers exist. This lack of standardization will affect how a jurisdiction handles a CW
incident and what role the dispatch center will play during a disaster. Many jurisdictions
may not have modernized equipment to support their present operation. It is anticipated
that even a modern dispatch center would be overtaxed during a CW incident.
9-1-1 Operators provide the com-
munication link between victims on
the scene and emergency responders.
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Law enforcement officers may become casualties either from being on scene at the time of
agent release (e.g., sporting event) or by rushing into a scene without proper precautions.
In these cases it is likely that a report of an "officer down" would be placed. Dispatch
operators are essential to linking the information on a chemical incident with the cause of
the officers' problem to keep other responders from rushing into the scene and becoming
additional casualties.
Recommendation.
Effective communications is the number one priority needed for the
successful command and control of any incident. The functional group suggests that all
emergency agencies do at least an annual test, evaluation, and update to all 9-1-1 and
dispatch centers. Some additional resources that may be needed to effectively handle a
CW incident include the following:
*
Additional 9-1-1 operators and dispatchers.
*
Additional 9-1-1 and telephone trunk lines in and out.
*
Additional dispatch radio channels.
*
Additional on-scene/fire ground channels.
*
Updated 9-1-1 and dispatch consoles.
*
Updated computers and programs.
*
Updated computer-aided dispatch (CAD).
*
Building security to include public access, weather, bombs, and terrorist factors.
*
Adequate commercial power.
*
Adequate automatic backup generator power supplies.
*
Upgraded telephone system to automatic number identification (ANI).
*
Alert protocol that addresses terrorist events specific to a CW incident.
Most jurisdictions should already have some form of 9-1-1 operators' checklist for
notification of a HazMat incident. This should be an appropriate starting point for
collecting information for a chemical incident. It is critical that information on the victims
symptoms, type of release, safe response routes, and other pertinent information be
provided to all responding personnel (e.g., police, fire, EMS).
Operators also normally have notification lists for various scenarios (e.g., bomb threats and
homicide). A similar list should be developed for a chemical terrorist event. A starting
point for the development of such a list would be from existing HazMat and terrorism
notification lists. It is imperative that rapid notification of this type of incident be made to
all agencies that may be affected to control and manage the incident and casualties. This
list should be developed with input from various organizations that will play a role in the
response to and management of a CW incident (e.g., hospital, fire, EMS, health depart-
ment, state and federal law enforcement). This list should reference all local, state, and
federal notifications. The development of this list may best be orchestrated through the
emergency management office for each jurisdiction.
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Issue: Multiple Agency Communications
Very few jurisdictions can expect to respond to and manage a chemical WMD incident
alone. All jurisdictions must be prepared to receive state and federal agencies responding
to the incident. Communications overload and the inability to link multiple agencies
communications systems are key restrictions that must be overcome.
Recommendation.
Communications between all responding agencies (e.g., fire, police,
emergency management, health, medical, mutual aid) and levels (local, state, and federal)
are key to a coordinated response effort. It is highly unlikely that jurisdictions will have
communications systems or assets to provide interagency communications between even
their local agencies.
From the outset of the incident response a Joint Operations Center should be established to
manage the response. This will most likely begin as a fire and police command post and
expand as other agencies arrive on scene. Liaisons to the JOC have the ability to
communicate with their own response agencies and across agencies through the other
liaisons at the JOC.
Emergency Response
Issue: Operations
Response operations begin with the initial dispatch for firefighters, rescue, HazMat, and
EMS personnel to respond to a request for assistance at a chemical emergency. This
information, in combination with preplans including building blueprints, maps, and utility
plats, helps the emergency responder formulate issues pertinent to the call.
Safety becomes the number one concern. Personnel on the first arriving fire apparatus on
approach to the scene should stop their vehicle at a distance and do an initial visual
assessment of the area. The North American Emergency Response Guidebook should be
used to determining initial hazard distances. This assessment will include any new
information obtained from bystanders, victims, or witnesses to the event. The officer on
the fire engine should confirm that all personnel on board are in full turnout gear, including
SCBA, and proceed with caution into the immediate area of the incident.
The senior officer on the first arriving apparatus assumes the role of the IC. After doing a
quick assessment, the IC must assign personnel to coordinate and manage both rescue and
decontamination operations. Handheld hose lines manned by firefighters will be the firstmeans of decontamination for victims and/or responders in the Hot Zone.Water flow for decontamination must be established quickly and maintained withoutinterruption. The initial water supply will be water from the booster tank of the apparatus.
Designated safety zones are determined and marked hot, warm, and cold. These zones not
only mark the site for the fire department personnel, but also establish a crime scene
perimeter for law enforcement during a CW incident. The zones will be secured by
firefighters, and only authorized personnel will be allowed access into these zones.
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Firefighters should plan and coordinate for a law enforcement presence inside of the Warm
Zone in order to assist with crowd control.
Additionally, secondary devices threaten the safety of emergency responders. Emergency
responders will need to coordinate with law enforcement to provide sweeps for secondary
devices in and around the incident scene.
The implementation of personnel accountability and identification should be in place.
Firefighters may need to perform rescue, HazMat, EMS, and decontamination operations inaddition to fire suppression duties because of the critical nature of the event. In a CW
incident, responder whereabouts can easily become confused, because many functions must
be carried out simultaneously. Law enforcement officers and any other response personnel
need to be included in the overall accountability of personnel operating in the hazard zones.
Rescue personnel, in addition to assisting firefighters, may be required to perform search,
extrication, securing, rigging, and removal of all known live victims. Rescuers should
wear a minimum level of chemical protection, firefighter turnout gear, and SCBA. In cases
of a CW incident, rescue personnel should not make any rescue attempts unless there are
known, live victims
.
HazMat technicians on all CW incidents are expected to be responsible for overall HazMat
operations, which will include detection, identification, containment, and decontaminationwithin the Hot Zone. These technicians should wear full Level
A encapsulated HazMat suits with SCBA for optimum
protection against chemical contamination. Law enforcement
personnel may ask HazMat technicians to provide detection
support during the processing of suspected chemical devices.
HazMat teams should be prepared to provide monitoring
assistance to law enforcement to reduce the size of the outer
scene perimeter. This reduction will free up additional officers
to assist with security inside the Warm Zone as well as
perform investigative duties.
EMS duties at a CW event require wearing proper personal protection. At a typical
HazMat scene, EMS responders are expected to operate only in the Cold Zone. Because of
the large number of casualties from a CW event, EMS responders may be required to
provide aid inside the Warm Zone. An appropriate level of chemical protective equipment
must be worn.
A CW incident requires a triage sector in the Warm Zone to prioritize patients for
decontamination and treatment. Further discussion of patient decontamination guidelines
can be found in the Health and Safety section of this part.
The massive amount of water needed to perform decontamination for a large number ofvictims raises questions of environmental concern. Water runoff can cause serious
overflowing or flooding of storm drains, ponds, lakes, streams, and rivers. Contaminated
water runoff should be controlled before it enters tributaries.
Rapid identification, marking, and
enforcement of hazard zones are
essential to protection of lives.
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Recommendation.
Responders from fire, rescue, HazMat, and EMS agencies must be
prepared to respond to any type of emergency at any time. This response requires a
constant state of readiness that is obtained through preplanning, regular response training,
and specialized response training. The IC needs to use the resources that already are on
hand: area maps, utility plats, charts, reference materials, training materials, technical
manuals, supplies, equipment, manpower, and emergency vehicles. These resources, in
addition to backup plans that address procuring supplies, equipment, emergency vehicles,
and manpower, are necessary because a CW incident may absorb multiple resources for
many days.
Because of the magnitude of a CW incident, the massive number of victims, and the
limited HazMat resources, the functional group recommends the
Guidelines for Incident
Commander's Use of Fire Fighter Protective Ensemble (FFPE) with Self-Contained
Breathing Apparatus (SCBA) for Rescue Operations During a Terrorist Chemical Agent
Incident
as the standard for firefighter PPE. This report gives guidelines and report
findings on the use of turnout gear and SCBA for a quick rescue of
known live victims,
at
the scene of a CW incident. This report is available for downloading at the SBCCOM
Domestic Preparedness Web site (www2.sbccom.army.mil/hld).
To help mitigate the effects of a chemical agent during the initial
fire department response, the functional group recommends that
jurisdictions review another technical report:
Guidelines for the
use of Positive Pressure Ventilation (PPV) Fans to Reduce Agent
Contamination in a Building,
which is available at the above Web
site.
A third report, titled
Guidelines for Mass Casualty Decon-
tamination During a Terrorist Chemical Agent Incident
, gives
detailed information on various methods and procedures for
chemical agent decontamination. This document addressescoordinating the decontamination of ambulatory and non-ambulatory patients. Decontamination issues that need to befurther developed; however, include cold weather
decontamination, rapid patient identification prior to decon-tamination, and the length of time each person must be
decontaminated to ensure they are free of the contaminant. This
report is also available at the above Web site.
Responders are also faced with the challenge of identifying, accounting for, and securing
the personal possessions removed from victims during decontamination. Thedecontamination process will be under control of the fire department, but it is expected thatlaw enforcement will assist with the accountability and security of personal property.
Issue: Command and Control
Command and control starts with the first arriving officer and remains until he or she is
relieved by another officer. The dispatch center performs a major role for the IC by
providing the communications link between different responding agencies. In cases of a
The Mass Casualty Decon-
tamination Report is one of
several studies documented
by the CWIRP to assist
responders in preparing for
domestic chemical terrorism.
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CW incident, the magnitude of the event will dictate an Incident Command System
(ICS)/Incident Command Management (ICM) response. The fire department will most
likely have initial control of the scene throughout the rescue of victims. Agencies
responding to the incident should provide a liaison to the IC to coordinate joint response
activities and share information. As soon as possible all responding agencies to the
incident should form a unified command in order to control and organize the multiple
aspects of the on-scene response. Once rescue operations are complete, control of the
incident will be handed off to the senior investigating agency on the scene.
The IC will need to immediately assume command and begin assigning sector command
responsibilities to prevent a CW incident from becoming out of control.
What is
established in the first hour of the incident will affect the first 24 hours of operation as
well as the long-term response and recovery.
The magnitude of a CW event will pose
extreme challenges to the rapid command and control of the incident.
Recommendation.
The key component to any successful operation is strong leadership.
Fire service leaders are charged with the responsibility for the preservation of life and
property in the community. These leaders must be multitalented not only in leadership
qualities, but they also must have a vast knowledge of all aspects of fire, rescue, HazMat,
and EMS operations. These individuals must learn, train, and retrain on all aspects of the
job to maintain their proficiency.
Company officers need to practice establishing ICS/ICM on smaller incidents to assist in
the overall command and control that is necessary in a large-scale event. Also, a juris-
diction should have a working knowledge of the area's capacity to handle an operation
involving a CW incident. After evaluating an incident, the IC should be able to identify the
resources he or she needs and know if they are available. Early requests for backup
resources will aid the overall command and control of a CW incident.
Issue: Scene Safety
Safety is the number one priority for all emergency responses. A safety officer should be
appointed who is responsible to oversee and control all responders as they perform their
duties. A CW incident, however, is laden with an inordinate number of concerns and may
be spread over a large area, which a single safety officer would not be able to effectively
mitigate. All responders must realize that no job is so urgent or important that they cannot
take time to perform their duties safely.
A CW incident's size and magnitude require a specific level of PPE. All responders on the
scene, including EMS, will be required to wear a certain level of PPE regardless of their
location on the scene. Chemical agent incidents require turnout gear, SCBA, HazMat gear,
and chemical suits.
In an act of terrorism, responders must also be cognizant of the threat that perpetrators may
still be on the scene and/or that secondary devices may be in the area. Staging areas,
casualty collection points, decontamination areas, and such are potential targets forsecondary attacks.
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Baltimore City EMT dons turnout
gear over a Tyvek suit prior to
assisting with casualties on a
CWIRP chemical response drill.
Recommendation.
Fire department SOPs should include a safety officer as part of the
command structure. Scene safety should be established as soon as possible and safety
guidelines adhered to at all times by all personnel. A CW incident may require a safety
officer for each sector or multiple sectors within the operation.
It is recommended that the safety officer have a working knowledge of all aspects of
emergency services. The individual must be familiar with departmental, local, state, and
federal safety regulations, procedures, policies, and protocols. Additionally, the safety
officer should be familiar with the technical reports and issues referenced in this Playbook.
Issue: EMS Activate Mass-Casualty Incident (MCI) Triage Protocols
A CW incident demands the use of MCI triage. Casualty management will start with a
quick triage, assessment, and prioritization of all casualties of the chemical event. The
CWIRP recommends the START triage system as it works well in a CW incident that
requires prioritization of a large number of victims. Patient status is color coded based on
their priority for treatment: Red for Immediate, Yellow for Delayed, Green for Minor, and
Black for deceased or Expectant. START is not, however, a national standard and many
jurisdictions do not adhere to it.
One major constraint to any MCI is that there will be many ambulatory and nonambulatory
patients who will all need to be decontaminated. This situation adds to the complexity of
triage. Ultimately, the process of moving patients out of the Warm Zone is considerably
slowed.
EMS providers assisting in decontamination operations shouldwear and use all required protection equipment. Safety pre-
cautions must be followed to guard against any direct contact
with victims or the chemical agent.
Once mass tagging of victims has taken place, the tagging of
personal belongings and decontamination of victims can occursimultaneously before the patient receives further treatment.
The number one treatment modality for CW victims is decon-
tamination. Additional treatment may also include
administering antidotes.
The large number of victims complicates patient tracking. Victims will initially be trackedby EMS according to their priority and destination status. However, many patients will
flee the scene without EMS having the opportunity to evaluate and/or transport these
patients to awaiting hospitals. EMS status reports should be considered only the first
echelon of patient tracking.After treatment and stabilization, casualties will be transported to available healthcare
facilities, off-site treatment facilities, and hospitals. Several modes of casualty transport
may need to be used to accommodate the large number of CW casualties.
Recommendation.
All EMS providers should be aware of and train on all aspects of
hazardous chemical contamination and methods of decontamination, including thoseCWIRP Playbook
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chemical agents used as WMD. A suggested learning resource is the Train-the-Trainer
program offered through the DPP.
The Improved Response Program (IRP) has developed guidelines for mass-casualty
decontamination. These are included in the Guidelines for Mass Casualty Decontami-
nation During a Terrorist Chemical Agent Incident
. This report explains methods of full
chemical agent decontamination and explains the methods of casualty prioritization as well.The use of the START triage system and knowledge of all medical protocols should be
practiced by all EMS providers.
Many agencies do not issue protective clothing and SCBA to EMS providers. It is
suggested that all EMS personnel be issued, be trained, and use, as a minimum level of
protection, firefighting turnout gear and SCBA or other respiratory protection.
Patient tracking recommendations can also be found in the Health and Safety section of thispart of the Playbook.
Mass-casualty transport may require enlisting public and private ambulances, public buses,
taxis, and police vehicles. These procedures should be part of a jurisdiction's planning
considerations and be outlined in standing operating procedures, memorandums of
agreements and emergency response plans.
Issue: Decontamination Support to Hospitals and Off-Site TreatmentCenters
In the event of a CW incident, hospitals will most likely request the fire department to
respond and provide decontamination operations at their facilities. In a large-scalechemical incident it is expected that all available fire assets will be consumed in the on-
scene response. Therefore hospitals should not rely on their availability to assist with
decontamination.Each hospital receiving casualties from a chemical incident needs the capability to establish
a water decontamination area at a designated entrance to each facility.This operation would be responsible for all walk-in casualties as well as any decontami-
nation of medical equipment, ambulances, or vehicles transporting casualties to each
facility. Verification of completeness of decontamination must be made before equipmentis returned to service.
Recommendation.
Hospitals should not expect the fire department to be available to assist
them in decontamination. Hospitals should have their own contingency plan that includesuse of their own buildings and grounds or maintenance departments. It is important to note
that garden type hoses do not provide sufficient water volume or pressure to provide
adequate skin decontamination. Hospitals would have to go to a fire hydrant to obtainadequate water flow and pressure.
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Law Enforcement
Issue: Incident Command
It is imperative that once a CW incident is identified, the first officer on scene acts as the
law enforcement IC until relieved by a senior official. Controlled response to a CW inci-
dent is essential for officer safety. Allowing officers to respond to a scene as individuals
until a supervisory officer arrives will most likely result in the majority of first responding
officers becoming casualties. Responders will rely heavily on the dispatch center to collect
and relay pertinent information regarding the situation as it unfolds at the incident site.
Since the response to a CW incident is going to involve multiple agencies, a joint command
center is necessary to coordinate the response. Throughout the rescue of victims, the senior
fire official on scene is most likely to perform the duties of the IC. As the incident pro-
gresses from emergency response to criminal investigation, so will the transition take place
from the fire department to law enforcement command and control of the scene. Any CW
incident will most likely be declared an act of terrorism, and the FBI will lead the overall
investigation.
Recommendation.
It is essential that the first arriving officer takes control of the situation
from a law enforcement perspective and not become too involved in the response. A rapid
assessment of the situation and identification of hazards must be made and relayed to
follow-on units to save lives and prevent casualties. Regardless of the rank of the first
responding officer, he or she must assume the role of law enforcement IC and that of
liaison with the fire department IC. All on-scene law enforcement activity should be
coordinated through this law enforcement IC/liaison officer since this person is responsible
for reporting the police activity to the overall IC. This procedure is essential for the safety
and accountability of all responders to the incident.
Close operations with the fire department IC will ease the transition from a fire to a law
enforcement command structure at a point to be determined by commanders. State or
federal law enforcement agencies may be on the scene by the time this transition occurs.
Local law enforcement agencies are expected to provide a liaison and to support the senior
level of law enforcement conducting the investigation.
Since police are expected to provide a liaison to the fire department during the rescue
operation, a fire department liaison should be made available to the law enforcement IC
during the investigative operation. Law enforcement will require fire department support
to provide decontamination and agent monitoring unless a self-sustaining team such as theFBI HMRU is performing the on-scene investigation.
Issue: Perimeter Security
Perimeter security for a chemical incident will differ from a standard crime scene in several
ways. The airborne vapor contamination will require that the initial perimeter be much
larger than the actual crime scene and, therefore, require a larger number of officers to
control. While the outer perimeter will be established in the Cold Zone, officers will still be
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threatened by cross-contamination from victims, shifting winds and/or additional chemical
releases.
The fact that victims are alive inside the perimeter without
protective equipment will provide a false sense of safety to
those outside the area. The threat of cross-contamination from
victims' clothing will not be visible. High-ranking officials
visiting the scene as well as relatives and news crews may
attempt to enter the outer perimeter. In addition to keeping
unprotected persons out of the secured area, it is necessary to
keep those who are still contaminated from leaving.
Recommendation.
Some form of initial control over the flow of personnel into and out of
the incident scene is critical. It is expected that by the time a sufficient number of
responders are on scene to provide an effective means of control, those who are intent on
leaving the scene will have done so already. The remaining victims will probably be more
cooperative in remaining on site, or are unable to leave and unless they become restless, the
majority of effort will be placed on keeping people out of the area. The external perimeter,
traffic control points, etc. should be reduced in size as quickly as possible based on
chemical monitoring of the area and advice of the HazMat team to reduce the impact on the
police department's manpower.
Level C PPE is recommended for officers manning the
perimeter. This level affords the key protection necessary
based on the contamination threat; however, wearing a
respirator severely limits the ability to communicate with the
general public.
The Law Enforcement Functional Group investigated the
legality of detaining someone intent on leaving the site that
had not yet processed through decontamination. Not all agents produce immediatecasualties or fatalities. Initial concerns were that an individual could unknowingly pose a
possible threat to the community through cross-contamination. Basic information
concerning the civil rights of these individuals leads to the following conclusions:
*
The individual could be forcibly detained if there was reasonable cause to suspect that
he or she were involved in carrying out the attack.
*
The threat of contaminating an area or person(s) outside the perimeter does not justify
the use of force.
*
In some jurisdictions, declaration of the incident as a public health emergency may
provide additional authority to law enforcement. This needs to be verified between law
enforcement and health officials as part of their planning and preparation for response
to a chemical incident.
*
All attempts within legal limits should be used to convince individuals to undergo
decontamination prior to departure from the incident scene.Level C PPE is recommended
for officers on the incident scene
perimeter to mitigate the threat
of cross-contamination.
Level C PPE consists of
a chemical protective
overgarment, negative-
pressure respirator and
chemical protective
gloves and boots.
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Issue: Crowd Control within the Incident Scene
In all likelihood, an incident of chemical WMD terrorism will be directed at a large
gathering of people to cause enormous casualties and fatalities. Mass confusion and
hysteria will follow such an attack. Law enforcement will play a major role in assisting
and controlling the affected population inside the hazard area. A calm and orderly
response from uniformed responders (police and fire) is essential in controlling the massive
numbers of people who may be involved in such an event.
Law enforcement presence in the Warm Zone is necessary to handle the situations con-
cerning crowd control that are beyond the scope of the fire department. It is expected that
some individuals will become confrontational with the firefighters who are separating,
segregating, and prioritizing victims for decontamination. As victims process throughdecontamination, they may be found in possession of contraband or weapons (possibly notrelated to the WMD incident) and other sorts of paraphernalia. Suspects may also be
identified among those awaiting decontamination.Recommendation.
This is an area where preparation, training, and equipment are essen-
tial for providing a controlled response. The instances outlined above are only some
reasons police involvement inside the Warm Zone is necessary. After these situations
arise, it is too late to begin thinking about a police response. Departments need to plan and
equip officers for operations inside the Warm Zone and decontamination corridors of achemical incident.
In a joint meeting of the fire and police representatives of the CWIRP, both groups dis-
cussed their objectives as they pertain to the need for mutual support. A major concern for
the fire department was a police presence inside the Warm Zone to provide additional
crowd control and safety for the first responders. The major concern of law enforcement
was to secure the external perimeter prior to initiating crowd control for the fire department
and first responders. Even though both sides agreed on the role of law enforcement, it is
expected that the response would not be automatic. The groups agreed on the following
two basic considerations:
*
The fire department needs to request support thru the senior police liaison on the scene.
*
The police department saw this role as essential to the overall control of the incident
and agreed that it should be supported as soon as they established police
command/control and perimeter security.
Issue: Witness Tracking, Interviewing, and DebriefingPolice interviews of potential witnesses to a chemical incident will be time consuming and
manpower intensive. Initial interviews to determine specifics of the incident and initial
descriptions of suspects need to focus on victims closest to the point of agent
dissemination. In the case of a major event (e.g., sporting event or concert) with thousands
of people in attendance, the only things distinguishing these individuals from the rest of the
crowd are their symptoms and injuries. The most severely injured and/or contaminated
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may have the most useful information; however, their treatment and transportation to
medical facilities cannot be delayed.
Most mass-casualty situations are derived from natural
disasters or unexpected accidents. In the case of a chemical
WMD incident, the fact that a deliberate criminal act caused
the incident makes the law enforcement role much more
significant. Accountability of everyone involved in the
incident is essential to police investigations.
Recommendation.
Patient identification and trackingbegin at the incident scene and should be part of any
jurisdiction's current mass-casualty response plan. The
overwhelming numbers of victims and limited medical
treatment facilities will result in patients being transported to many different locations.
Police must coordinate closely with fire and EMS to identify the disposition of victims for
them to be interviewed by investigators.
Investigators should coordinate with the medical community to identify any people who
entered the healthcare system on their own reporting symptoms that indicate they may have
been part of the chemical incident.
Law enforcement should establish an area to conduct interviews that is close to the incident
scene for rapid processing and dissemination of information to the incident command post.
This area must take into consideration that victims will have undergone decontaminationand need a place to stay warm and possibly seek further, non-urgent, medical care.
The CWIRP recommends that the local health department provide a specific station to
conduct victim interviews at its off-site treatment facility. This facility can be an extremely
useful collection point of witnesses since all noncritical patients from the scene will be
transported there as well as victims seeking critical incident stress management (CISM).
Conducting interviews at the off-site facility and obtaining available building space should
be coordinated with the agency responsible for its operation (normally the health depart-
ment).
Issue: Airspace Management
One major concern during a CW incident is to contain the spread of the chemical agent,
particularly when aircraft downdraft can proliferate further contamination. It can be
expected that citizens will be concerned about news helicopters recording them processing
through decontamination, where disrobing is recommended as part of the process.
Controlling airspace over an incident is difficult because law enforcement routinely use
helicopter support to control the scene. Moreover, many media organizations will try to
use helicopters to obtain better visual coverage. Containing the spread of the contamina-
tion warrants strict management of airspace over a CW scene.
Recommendation.
Immediate declaration of airspace restrictions should be made as soon
as a chemical incident is suspected and it should be maintained until all airborne
Detectives interrogate an actor por-
traying a potential suspect during one
of the CWIRP functional exercises.
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contamination is mitigated. Police aviation assets should also assist in enforcing airspace
restrictions around the incident site.
Health and Safety
Issue: Triage/Decontamination PrioritizationTriage priorities differ during a CW incident. The emphasis is placed on decontaminating
victims prior to treatment to avoid spreading the contaminant. It is also important to
decontaminate the patient as a means of treatment to prevent prolonged chemical exposure.
Only in certain instances, such as intubation, does treatment take precedence over
decontamination.Recommendation.
The program recommends using the START triage system for mass
casualty triage. This system is incorporated into the guidelines for mass-casualty
decontamination that are cited in SBCCOM September 9, 1999, Guidelines for Mass
Casualty Decontamination During a Terrorist Chemical Agent Incident. This document
provides guidelines for prioritizing casualties for decontamination and treatment. Thereport is available via the SBCCOM Web site at (www2.sbccom.army.mil/hld).
Issue: Casualty TrackingIdentification of personnel from a terrorist incident scene is critical to the law enforcement
investigation as well as the care of patients. Tracking patients from any mass casualtyincident is a enormous and time consuming task. Without hindering the patient care
responders should make every attempt to assist in the identification and tracking ofpatients.
Recommendation.
Patient tracking should include the use of a waterproof triage tag thathas multiple peeloff bar code/serial number stickers. These stickers allow EMS personnel
to quickly process patients through the triage, treatment, and transport sectors because they
can place the bar code sticker on their rosters without having to rewrite patient name,
status, and destination. The stickers also help identify patient belongings that could be
returned later. EMS status reports should be considered the first echelon of patient
tracking.Issue: Mass-Casualty Transport
During a CW incident, transport of multiple patients to various healthcare facilities can be
a complicated process. Also, there will likely be a larger victim population than in most
other kinds of EMS responses. It is important to control these patients and get them to
definitive care in a timely manner; otherwise, they may flee the scene attempting to obtain
medical care on their own.
The use of mass transit vehicles and other means of public transport is often an acceptable
means to provide mass-casualty transport. This method requires careful consideration since
a CW incident creates multiple concerns:
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Mass transit vehicles are expected to
play a key role in the transportation
of noncritical, decontaminated casu-
alties.
*
Who will drive the bus and what kind of PPE does the driver need to wear?
*
Is the vehicle decontaminated prior to being put back in service?
*
Who determines that the unit is adequately decontaminated?
*
How many healthcare personnel are needed on the bus during patient transport?
*
Will citizens ride in a bus that was used to transport decontaminated victims?
Recommendation.
An MOU should be established between the community and its mass
transit assets or a school bus company so that buses can be used for the purpose of mass-
casualty transport. Decontaminated walking wounded and patients who are triaged minor
(green) should be transported to the Off-Site Triage, Treatment, and Transportation Center
for further treatment and evaluation. Patients triaged as urgent or immediate (red or yellow)
should be transported by ambulance directly to a medical treatment facility. It is recom-
mended that each ambulance carry more than one patient, if possible.
An EMT or EMT-P should accompany patients on the bus,
oversee patient status, and render necessary care. It has not
been determined how many EMS personnel are needed to
staff this type of patient transport, because it is dependent on
the situation and expected chemical agent.
There is no recommendation regarding who should operate
the bus. In the case of the agencies supporting the CWIRP,
it was agreed that normal bus drivers would not operate the
vehicles. It is recommended that operators wear Level-C
PPE.
The route to the facilities (e.g., hospitals, off-site treatment center, mental health support
site) should be planned and cleared by police to promote easy egress and ingress and rapid
return of transport vehicles.
The bus will need to be put out of service until it has been decontaminated and verified safe
for public use. Determination of the effectiveness of decontamination should be coordi-nated between the local jurisdiction and the Environmental Protection Agency (EPA).
Issue: Hospital Security
To protect their facility and personnel from becoming contaminated, hospitals need to
establish plans for controlling access during a chemical terrorist event. Hospital security
should be prepared to handle a large influx of patients who may become unruly as hospitals
establish one entry point to the facility. Victims may begin to panic knowing that they
were a part of a terrorist event and need to be decontaminated and believing that the limited
admission process inhibits their access to definitive care. Security personnel become the
first line of defense to controlling crowd behavior.
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Controlled entrance to hospitals
is essential to ensure facilities
are not contaminated.
Further complicating the hospital security issue is the fact that many hospitals employ off-
duty police offers to supplement their staff. During a CW incident these officers may be
recalled to their full-time departments to provide backup support to the overall operation.
Hospitals may then be understaffed to adequately provide crowd control.
Recommendation.
Security personnel should wear Level-C
PPE for protection from casualties who may have
contamination on their clothing. This is the same level of
protection recommended for the police officer performing
perimeter security. Security personnel should also go through
a decontamination line at the end of their shift, to minimizeany potential exposure.
Hospitals should have an accurate inventory of personnel who
are capable of providing support during a CW event. These
plans should also include an attrition of personnel because
some officers may inadvertently become contaminated and unable to render support.
Hospital security departments should seek to supplement their staff through other means.
Issue: Hospital Triage/Decontamination OutsideDuring the first hour of a chemical terrorist attack, hospitals may experience a large
number of patients-walking wounded, worried well, citizens who live near the scene
believing they need to be treated, and private vehicle arrivals seeking treatment. Hospitals
could become inundated with patients as victims from the scene are added to their normal
patient load. Suddenly, hospitals will be responsible for differentiating between these two
patient populations and deciding who needs to be decontaminated and how they should be
triaged, treated, and, if needed, transported to another facility.
Hospitals generally do not have much experience rapidly triaging a mass number of
patients. In addition, most are not prepared to perform mass decontamination operations.Also, Emergency Departments do not have the room needed to set up a triage area that aids
the overall ability to treat numerous victims.
Recommendation.
Hospitals should coordinate with the emergency response and
emergency management agencies to ensure that they are included in the notification
sequence once a chemical agent incident is suspected. This early notification will assist
administrators in preparing for the potential of contaminated casualties self-referring to
their facilities.
One entry point into and out of the hospital should be determined during a chemical
terrorist incident. This controlled access helps to avoid secondary hospital contamination
that could potentially shut down the facility.
An outside staging area should be established near the entry point so that patients can be
segregated as those decontaminated at the scene, those not previously decontaminated, and
those not part of the CW incident. Workers manning stations outside of the hospital should
wear Level C PPE as the minimum recommended level of protection from cross-
contamination.
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The goal of the staging area should be to establish control of the victims and restrict them
from entering until they have been properly decontaminated and triaged. It may also
become necessary to instruct victims who show up by personal vehicle to go to an off-site
treatment center and to decontaminate anything they have touched since the incident.
Hospitals nearest to the incident may need to arrange patient transportation to an off-site
treatment center or to an outlying facility when their resources are overwhelmed.
Guidelines for establishing an outside triage area can be found in the chapter marked Non-
Ambulance Transport of Casualties in the book
Disaster Response: Principles of Prepara-
tion and Coordination
by Erik Auf der Heide and
The Public Information Chapter as
Specified in the Trauma Care System-Guide to Planning, Implementation, Operation and
Evaluation
by Cales & Heilg, Jr., 1986.
Hospitals should not expect the fire department to be available to assist them in
decontamination. Hospitals should have their own contingency plan that includes use oftheir own buildings and grounds or maintenance departments. It is important to note that
garden type hoses do not provide sufficient water volume or pressure to provide adequate
skin decontamination. Hospitals would have to go to a fire hydrant to obtain adequatewater flow and pressure.
Issue:
Logistics for Sustained Operation
The ability to sustain operations and recover from a disaster is dependent on the system
enacted during the first hour and the long-range plans made to handle potential compli-
cations. Along with rendering care to CW victims, hospitals need to continue to provide
care to the regular influx of patients. Disaster plans do not adequately address rendering
care to both patient groups for a sustained period of time. Patients exposed to chemical
contaminants may need to be admitted to intensive care units (ICUs) requiring cardiac
monitoring, regular administration of medication, and ventilation support, as well as
medical staff to provide this care.
Recommendation.
Hospital administrators should coordinate their planning and response
efforts with the National Disaster Medical System (NDMS) assets such as the Disaster
Medical Assistance Team (DMAT) and the American Red Cross who are capable of
providing medical support and medical staff.
Before external help arrives, hospitals may need to temporarily change the nurse or
technician to patient ratio to provide care to a larger number of patients. Hospitals should
also build into their disaster plan a means of acquiring more emergency department and
front lobby personnel because these people may become contaminated should victims rush
hospitals for treatment.
Issue: Use of Terrorism Annex in Disaster Plans
Hospitals accredited by JCAHO are required to have the hospital's disaster plan available
in each department. Since this document is so rarely used, most staff members are
unfamiliar with it. Unfortunately, department managers who are the most familiar with this
plan do not work 24 hours a day, 7 days a week (24/7). Clinical "charge" positions are
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generally created in 24/7 operations, but these persons are often not well informed of the
hospital disaster plan.
Recommendation.
Hospitals should have a terrorism annex that also addresses weapons
of mass destruction as part of their disaster plans. The written plan should be in a
convenient location that is also easily accessible. Quick charts of antidotes for CW patients
could be placed on walls by telephones. Annexes describing different scenarios should be
well labeled and easy to read (e.g., chemical weapons, biological weapons, mass
decontamination). Also, the annexes should describe specific actions that the departmentshould take, since each type of response requires events to be prioritized differently.
Emergency Management
Issue: Event Awareness
The emergency management community is not likely to be aware of an incident in its early
stages. First responders will be on their own to assess the situation, provide assistance to
victims, and gain and maintain site control. The organization, infrastructure, staffing, and
lines of communication among the emergency management and first responders vary
across the country. Based on discussions conducted throughout the course of the BALTEX
series of exercises and conferences, members of the emergency management community
believe that they will first be apprised of the situation based on the following:
*
Media, via radio or television.
*
Monitoring of first responder radio transmissions.
*
Large number of casualties associated with incident.
*
Extensive property damage.
In many cases throughout the country notification comes as a result of media involvement
(e.g., CNN and local news station). Unfortunately, as far as public safety and information
is concerned, emergency managers may be immediately put into a damage control posture.
Many agencies monitor police and or fire department radio communication because this
offers the best venue for accurate information. The rapid collection and dissemination of
accurate information is essential to maintaining public confidence.
Recommendation.
Emergency managers should be part of the rapid notification
system/list supporting the communities response to a suspected chemical agent incident.
Emergency managers should review their operations plans with their supporting first
responders and in conjunction with state and federal emergency managers.
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Part IV Follow-On Response: The First Day
Once the immediate response and lifesaving procedures are in place, a jurisdiction needs to
focus on the coordinated response to manage the incident. A chemical WMD incident will
result in an overwhelming amount of local, state, and federal resources responding to the
scene. Management of these resources and their integration into the planned response will
be a major challenge to a city. Within 24 hours local mutual aid, state resources, and local
federal support (branch offices) will arrive on the scene.
This section outlines key issues and recommendations facing a jurisdiction after the initial
lifesaving response measures have been conducted.
General
Issue: Stress Management of Emergency Personnel
It is expected that a CW terrorist incident will create an extremely stressful situation for
emergency responders. The effects of stress on the individual may be immediate or
delayed and will vary from person to person. It will have a direct impact on the emergency
responders' ability to properly perform their duties.
Commanders should look for personnel displaying the
following stress-related warning signs:
*
Headaches
*
Blurred vision
*
Vomiting
*
Isolating themselves from other responders
*
No response or slow response to commands
*
Acting confused, argumentative, or disillusioned
Responders face dangers and save
lives everyday; however, the psy-
chological strains associated with a
deliberate MCI must be understood
and addressed.
...the Panel believes that the historically more frequent, lesser consequence terrorist
attack, is more likely in the near term one involving a weapon on a relatively small-
scale incident, using either a chemical, biological, or radiological device (and not a
nuclear weapon), or conventional explosives. Rather than having the intention of
inflicting mass casualties, such an attack could be designed to cause a limited
number of casualties, but at the same time cause mass panic. ... Nevertheless, even
limited casualties could precipitate a disproportionate psychological response among
the public. The resulting panic by citizens who perceive that they have been exposed,
but who (like many in Tokyo) in reality have not been exposed, could effectively
paralyze response capabilities even among the most prepared.
First Annual Report to The President and The Congress of the Advisory Panel to
Assess Domestic Response Capabilities for Terrorism Involving Weapons of Mass
Destruction. RAND 1999, Washington D.C.
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* It is noted that several of the above warning signs are also symptoms of nerve agent
poisoning. It may be difficult to tell if the symptoms are related to stress or prolonged
agent symptoms.
Experience from the Oklahoma City bombing indicated that stress debriefings had to be
mandated to ensure that they were accomplished. Many responders did not willingly want
to participate and actively sought ways out of the debriefings.
Recommendation.
One important factor to the responders involved in the Columbine
incident was the ability to notify family members of their status. Telephone communi-
cations to inform family members that they were not a casualty of the incident was
extremely important. This means of stress management should be considered for any
major response effort.
It is also recommended that critical incident defusing take place before personnel are
released from their duties and sent home.
Twenty-four hours after the incident, an official mandatory debriefing should be
implemented.
Jurisdictions should update their employee assistance programs on the impact of the event
and their companies' role at the scene. Commanders should continue to look for signs of
stress well after the event.
Another important element in handling stress management is each individual's right to
privacy. Some responders do not wish to disclose their condition. Caution must be used
not to violate this issue, as the person may or may not accept stress treatment if his or her
right to privacy is violated.
Emergency Response
Issue: Safety and Security
Emergency responders and law enforcement officials will need to work together in a CW
terrorist event to ensure the safety and security of the entire scene. Police agencies may or
may not be equipped with the adequate level of PPE. This could require emergency
responders to perform the additional tasks of limiting access to the Hot, Warm, and Cold
Zones.
Additionally, secondary devices threaten the safety of emergency responders. Emergency
responders will need to coordinate with law enforcement to provide sweeps for secondary
devices in and around the incident scene.
Monitoring for agent contamination is essential in determining safe operating zones, levels
of protective equipment and identification of agent if possible. Law enforcement agencies
are not expected to have chemical agent detectors and will require assistance from the fire
department's HazMat team.
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Recommendation.
Communication and shared information between emergency
responders and law enforcement is a must to maintain safety and security on the scene.
Emergency responders need to advise law enforcement on the proper levels of protective
equipment needed for officers' safety. The minimum level recommended for officers oper-
ating on the perimeter and in the Warm Zone is Level C.
Issue: Environmental Concerns
Decontamination of a large number of people will lead to water runoff that will be difficultto mitigate. Emergency responders are responsible for avoiding spreading the contaminant.
Water runoff is likely, but should be contained to the best extent possible.
Contained water runoff will need to be tested and monitored to determine the appropriate
disposition. This must be closely coordinated with EPA and local environmental
regulations.
Uncontained runoff may have long-term environmental effects both because of the level of
contamination and the release of massive quantities of water into the environment.
Recommendation.
There currently are no acceptable
levels for military chemical agents in the civilian
environment; however, it is recognized that the task of
containing all the water from a chemical MCI is
impossible. Because of this, guidance was sought from
EPA concerning the liabilities of a community in
performing mass-casualty decontamination operations inresponse to a chemical terrorist event.
EPA responded in a letter stating that contaminated water
runoff is not considered an act of negligence when
emergency responders undertake necessary action to save
lives and protect the public and themselves. This EPA
response is included in Part VIII of this Playbook.
EPA's standing on contaminated water runoff, however, does not eliminate the responsi-
bility to control the flow of water into the local environment. Steps must still be taken to
prevent erosion and other environmental impacts resulting from the release of massive
quantities of water.
Contained water must be monitored and approved for release into the environment or
properly classified for disposition in a hazardous waste site.
Issue: Procedures for Prolonged SCBA Operations
Emergency responders working within the contaminated areas of a chemical agent event
will be required to operate for prolonged periods using SCBA. The recommendations of
the CWIRP as outlined in the
Guidelines for Incident Commander's Use of Firefighter
Protective Ensemble with Self-Contained Breathing Apparatus for Rescue Operations
Trace chemicals in runoff and other
environmental affects of mass-
casualty decontamination are con-cerns; however, saving lives takes
precedence.
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Each phase of recovery must
be supported by decontamina-
tion teams.
During a Terrorist Chemical Agent Incident
indicate that firefighters in standard bunker
gear and SCBA can operate in a contaminated environment to perform a quick rescue of
known live victims. However, the normal practice of donning SCBA before entering a
building and removing it immediately upon exit is inappropriate for a chemical incident.
SCBA must be donned prior to entering the Warm Zone and is the last item removed as the
firefighter processes through decontamination. The time needed to process through decon-tamination makes it essential that firefighters exit the contaminated area immediately when
their warning bell activates.
Recommendation.
Technical decontamination must be established for processingresponders operating in the Warm and Hot Zones. Firefighters should be trained on the
technical decontamination procedures normally reserved for HazMat operations.Additional air supplies should be at the decontamination area so that firefighters whoexhaust their tanks can do a quick switch before proceeding through decontamination.SCBA used inside the Warm or Hot Zones must be decontaminated to EPA standards or
left in the Warm Zone for safe disposal..
Issue: Decontamination Support to Recovery OperationsTechnical decontamination is normally established for HazMatoperations only. A CW incident requires multiple agencies that
do not have their own decontamination capabilities to operate inthe Hot and Warm Zones. Emergency response needs to main-
tain technical decontamination throughout the incident to assistother agencies during their recovery operations.
Specific support to law enforcement can be expected to include
decontamination of evidence containers and sensitiveequipment to include firearms. The decontamination ofsensitive equipment will be under the supervision of law
enforcement, which will also provide security over the same.
Gross level decontamination of the deceased will need to be conducted on scene before themedical examiner can take possession of the bodies. This must also be closely coordinated
with the investigating law enforcement agency to preserve any evidence they will need.
It is also expected that the fire department will be asked to assist with the gross level
decontamination of major equipment, including vehicles, that may have been in the Warmor Hot Zones and/or have transported contaminated casualties.
Recommendation.
Emergency responders need to work closely with all agencies involved
in the recovery operation to ensure that all decontamination requests and procedures areprovided.
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The reality exists that major
response items may be lost
temporarily or permanently
because of contamination.
* The following is a special note pertaining to decontamination efforts during non-emergency response phases.
EPA states that government jurisdictions can be found negligent when contaminated water runoff
results from decontamination efforts performed during nonemergency response phases. Waterfrom these types of decontamination operations must be collected, containerized and disposed of inaccordance with regulations governing hazardous waste management.
Issue: Manpower Replacement
Managing a CW incident is labor intensive. Additional manpower is required to perform
decontamination operations, and specialized personnel, such as HazMat technicians, areneeded to perform critical tasks. Issues that complicate the availability of manpower
include loss of personnel because of contamination or exposure, injury, fatigue, and stress.
Recommendation.
The IC needs to monitor the status of all personnel on scene and
ensure that they are capable of performing their duties. Medical screening should be
conducted on individuals at the completion of their mission. Coordination for additional
manpower to include special skills may be necessary to provide continual operations.
Issue: Replacement of Supplies, Equipment, and Apparatus
Most jurisdictions and departments have a limited amount of resources to perform normal
daily operations. In a CW incident, it is expected that resources will quickly be depleted
and/or may become contaminated.
Items that are normally consumed on a daily basis will be easier
to replace in a timely manner. Other items, such as turnout
gear, SCBA, and apparatus, are not readily available. The loss
of these items not only hinders the ability to continue operations
at the chemical incident scene, but also affects the jurisdiction's
ability to perform daily operations.
Recommendation.
A contingency plan for replacing equip-
ment used during a CW incident should be in place. It should
include a list of stockpile locations, mutual-aid equipment,
equipment vendors, and equipment manufacturers. This list
should be readily available at all times both on the scene and in the station for immediate
access by those personnel responsible for equipment acquisition. This plan should include
temporary and permanent replacement options.
Issue: Field Communications
Communications systems are effective when operated up to a predetermined peak load.
They are not reliable during periods of saturation. Responders must realize communi-
cations and equipment being used both on and off site during a CW event are vulnerable to
interruptions, breakdowns, total failure, damage, loss, and contamination. Alternate means
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of communication must be in place. Additionally, perpetrators of a CW event may also
purposely disrupt communications systems to further hinder the response effort.
Recommendation.
All emergency agencies should have contingency plans in place for
dealing with communications loss. These plans should include automatic, systemwide
backups that are enforced upon communications failures. The final alternative should be a
complete manual system such as runners. These procedures should be practiced on a
regular basis during routine emergency response exercises. Alternate means of communi-
cation can include the following:
*
Spare or replacement radios and radio supplies
*
Mutual-aid radio and communications equipment
*
Private radio equipment
*
Hard-wired telephones
*
Wireless telephones
*
Wireless data links
*
Fax machines
*
HAM radio
*
Message runners
Communications systems that are dependent on batteries require frequent replacement or
recharging of batteries for continual operations. Experience in the Columbine High School
attack showed that 4 hours of constant use was the average limit for batteries due to the
high volume of use.
Law Enforcement
Issue: Evidence Collection and DecontaminationOnce the threat of airborne chemical contamination has been eliminated, law enforcement
is still faced with processing a crime scene where a large part of the physical evidence may
be contaminated. This is particularly true with the more persistent chemical agents such as
VX and mustard. Local crime lab members are not normally trained or equipped to
perform this task. In addition to the physical hazards of collecting contaminated evidence,
law enforcement must consider that decontaminating evidence may subsequently destroy
(contaminate) critical components of the investigation. This concern precludes decontami-
nating evidence on the scene to facilitate collection and processing.
Recommendation.
Since an attack with chemical agents will most likely be declared an
act of terrorism, the FBI will lead the criminal investigation. The FBI's Emergency
Response Team (ERT) is best suited to collect the evidence from such a scene. Local law
enforcement should limit their involvement to the security and preservation of the scene
until federal assets arrive.
Evidence samples of the chemical agent do not need to be hurriedly collected because
potential evaporation or degradation is not a concern. A significant amount of military
scientific information substantiates that chemical agent evidence can be drawn from trace
elements of the agent by-products.
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Chemically contaminated evidence should be packaged on scene and the detailed decon-
tamination conducted at the laboratory. Law enforcement should decontaminate the outer
package on the scene prior to transferring the evidence to a lab.
Issue: Decontamination of Law Enforcement OfficersPerforming operations in a contaminated area requires personnel to undergo
decontamination operations prior to being released from the incident scene. Normallydecontamination is only performed by HazMat teams. This process is relatively new tomost first responders especially law enforcement. In addition, equipment that enters a
contaminated area to include that that is worn by an officer must be decontaminated before
it is released from the scene. The following issue outlines equipment decontaminationconcerns.
Decontamination is the process whereby the threat of contamination is reduced throughdeliberate and controlled protective clothing removal and/or agent removal from such
clothing. The type of decontamination process is normally determined based on the type ofprotective clothing worn. It is imperative that law enforcement officers operating in
contaminated areas understand decontamination procedures and processes prior toinitiating operations in a contaminated environment.
Recommendation.
Prior to commencing any operation in a contaminated environment law
enforcement must ensure that decontamination assistance is coordinated for and available.Experience through exercises indicates that all to often this is assumed and not properly
coordinated. It is recommended that, subject to the availability of resources, responder
decontamination be established separately from that processing the general public. Thiswill ensure that decontamination is available for responders when needed and allow forspecial situations that pertain to the responder (i.e. security and decontamination ofofficers' weapons).
Decontamination for HazMat teams is normally referred to as technical or detaileddecontamination. Since HazMat suits are water repellant, procedures for decontamination
consist of washing off the suit with hoses and water sprays prior to disrobing from the suit.This form of decontamination is acceptable for the protective ensembles that the IRPrecommends for patrol officers but not for those recommended for SWAT. The charcoal
style ensembles, such as those recommended for SWAT, should not be wet. Getting these
types of suits wet degrades the protective qualities of the suit and may serve to transfer
agent trapped in the charcoal layer through the suit on to the wearer. Charcoal ensembles
should be removed through a careful and controlled disrobing process. This processbasically entails using an assistant or "buddy" to remove the overgarment so that the
wearer does not touch the outside (contaminated) part of the suit while moving through a
controlled process that reduces the danger of contamination as the procedure is performed.
Details for conducting such decontamination will be included in the law enforcement PPEreport that will be published an the SBCCOM Web site after completion of the ensemble
testing.
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Note:
Regardless of the type of suit worn and decontamination procedures used, therespiratory protection (mask) should always be the last element of the protective ensemble
to be removed.
Issue: Decontamination of Law Enforcement EquipmentThe threat that officers and/or their equipment will get contaminated because of a chemical
WMD incident is real. In the case of a large public gathering (e.g., concert and sporting
event), officers may already be on the scene and become part of the initial casualties from
the attack. Additionally, the first responding officers to a chemical incident may not
immediately realize the hazard and may enter a contaminated area. Regardless of how the
exposure occurs, departments must be prepared to handle the problems associated with
processing law enforcement equipment through decontamination. Of particular concernare weapons, radios, badges, and other highly sensitive equipment. This problem can
quickly extend beyond the realm of the individual officer's equipment to include patrol
vehicles, robots used to handle bombs (secondary devices), and other specialized team
equipment.
Equipment known or suspected of being contaminated must be decontaminated and
monitored before it is returned to service. Based on the amount of equipment in question
and the need to maintain a community response capability, the senior law enforcement
representative from each department must determine the amount of decontamination andmonitoring that will be performed on essential equipment.
Recommendation.
Contaminated equipment will be separated
from the officers at the decontamination line inside the WarmZone. Officers are not expected to willingly relinquish their
equipment to anyone other than a supervisor from their own
department. Departments need to be prepared to provide
someone inside the Warm Zone who is responsible for the
security and processing of contaminated law enforcement
equipment. This individual must be properly equipped with
PPE.
Small, nonelectronic equipment can be placed in a bucket or container of bleach. A
lockable container is recommended because the equipment will have to remain in the
solution for a considerable amount of time (15 to 30 minutes for most agents). Since most
decontamination solutions are going to be in liquid form, ammunition should be removedfrom firearms and processed separately. Electronic equipment should be double bagged
and processed by a laboratory with appropriate guidance based on the agent involved.
All equipment should be monitored to validate the effectiveness of decontamination priorto being returned to service. The level of monitoring should be discussed and approved
with on-scene safety officials. Compounding the issue of effective decontamination is thefact that there are no standards established by OSHA or EPA for military chemical warfare
agents in the civilian community. The more readily available types of monitoring devices
expected to be in possession of the local response community (e.g., M8 paper and chemical
agent monitors) provides only gross level detection capabilities. A more detailed level of
Decontamination and security oflaw enforcement are challenges
that must be closely coordinated
between responder agencies.
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monitoring, a time consuming process, is necessary and requires equipment that will
probably be available only through federal assets.
Small quantities of equipment (e.g., handguns and radios) may be replenished through
inter-departmental resources or through mutual-aid support while the contaminated equip-
ment is processed. Equipment obtained through mutual-aid support must be compatible
with the gaining department's equipment (e.g., communications and weapons) to be a
viable solution to the immediate situation. Otherwise, to continue to provide service to the
community, department supervisors may have to decide on returning equipment to service
based on results from lower levels of monitoring.
Issue: Security of Victim's Personal Effects
Decontamination studies reflect that the majority of contamination is removed by removalof the outer clothing from an exposed victim. Those individuals who were close to the
agent release point are likely to have agent trapped in their clothes. The first step of
processing anyone through a chemical decontamination is to remove as much of theirclothing as they will permit prior to washing them down. The clothing and personal effects
must be bagged, the owner's identity recorded, and the belongings secured until a
determination is made on its disposition.
The fire department will handle the processing of victims through decontamination, but lawenforcement must be prepared to handle the security of the items collected. An additional
interest to law enforcement is the fact that the perpetrator(s) may be among those
processed.
Recommendation.
The items collected must be segregated and labeled with the owners'
identification. This is essential to the investigation if law enforcement determines that
someone connected with the criminal act was processed through decontamination. Therights of private citizens concerning probable cause, however, prohibit law enforcement
from processing all collected items when looking for evidence.
Items collected from victims will include sensitive items such as keys, wallets, purses, cell
phones, and pagers and may not be willingly surrendered. The fire department may elect to
bag these items and allow the owner to process through decontamination with them. If lawenforcement wants all the belongings of a certain individual (i.e., a suspect to be detained
for questioning after decontamination) to be collected, they must relay this to the firedepartment IC. Law enforcement should be available to assist with the collection of items
from the individual for chain of custody reasons.
Senior officials from the responding agencies as well as local emergency management
personnel must determine who has the overall control and disposition authority over the
collected personal items.
Issue: Security of Critical Facilities
There are two types of critical facilities that law enforcement may be asked to assist in
securing during a chemical attack. The first will be those facilities associated with the
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processing of casualties from the incident. The second are other key areas that may be the
target of additional attacks.
Hospitals and off-site medical treatment centers must establish limited access to keep their
facilities from becoming contaminated. This controlled access may cause confusion among
the population. Patients may perceive that they are being denied access to care, which
could result in panic and unruly conduct.
Just as the threat of secondary devices targeting responders has become a reality, the
possibility that the initial attack is part of a series of attacks or a diversion from a separate
attack must be considered.
Recommendation.
Local law enforcement may not have the manpower to simultaneously
handle the incident response and security issues at other locations. Those locations with
internal security should do the best they can with their own resources. It is recommended
that law enforcement maintain a rapid response team capable of responding to any
disturbance that may occur at these locations.
Police intelligence, in conjunction with the local emergency management office, should
notify other key areas that are possible targets. Increased security and awareness should be
stressed, as well as procedures to report suspicious activities or threats. If there is a clear
"theme" to the initial attack (e.g., political, social, racial) similar such groups, organiza-
tions, and gatherings, should be warned.
Health and Safety
Issue: Casualty TrackingTracking patients from the incident site through the healthcare system is a complexprocess. EMS, triage, and transportation officers, police investigators, and hospital
personnel must identify patients as having been part of the same incident. Identification of
all casualties is of paramount concern to assist with public inquiries on the status of people
who may be involved in the incident as well as the criminal investigation.
Recommendation.
Many patients will enter the healthcare system on their own. Thus,
there's a need that hospitals track all patients from the same incident by creating a written
log or database. Agencies, including EMS, hospitals, clinics, off-site centers, mass-
casualty care shelters, and the like, should update their logs every 12 hours and report their
information to a central location. Typically, jurisdictions establish a "reunification center"
to help family members locate their loved ones or to make a missing persons report.
Issue: Disposition of Animal Carcasses
As a chemical agent spreads, all life that exists in the area is subject to exposure. Animal
carcasses found in the area should be considered contaminated and their location docu-
mented, and then they should be removed to maintain public health and safety. Animal
control agencies are often not aware that a basic level of PPE should be worn when
collecting suspected contaminated carcasses.
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Secondly, these carcasses need to be contained, because they are considered crime scene
evidence of a CW terrorist attack.
Recommendation.
The health department should notify the office of animal control with
information pertaining to the level of PPE and means of containment. It is recommended
that animal control personnel, to avoid self-contamination and cross-contamination, wear a
minimum of Level-C PPE.
Carcasses should be temporarily stored in 55-gallon drums that can be sealed to avoid
chemical agent off-gassing. Once law enforcement collects the samples they need for the
investigation, the rest of the remains can be incinerated.
Issue: Mental Health Concerns Victims Community
Emergency response organizations have programs in place to deal with the emotional stress
of responders. Even with such counseling, there is still a vast effect on the mental health of
responders as is evidenced in the long-term study of responders to the bombing of the
Oklahoma City federal building.
It is expected that the community's mental well-being may be affected because of the
trauma associated with a chemical terrorist incident. The number of dead and contami-
nated will concern the larger community as people realize they are vulnerable to such
terrorist acts. The contaminated area may result in quarantining residential areas, leaving
people without homes. Many worried-well, those who would not be physically affected by
the incident but would be emotionally overwrought, will not be able to cope and may enter
the healthcare system for emotional support.
Recommendation.
The local health department should set up a mental health outreach
center for victims and for the community at large. Critical incident stress debriefing
sessions should be organized for the community.
Public announcements should be made specifying the location of the mental health site and
encouraging the community to seek help. This center can be collocated at the OST
3
C;
many patients who will enter the center will benefit from some form of counseling.
The mental health site should be linked to the patient tracking system and serve to assistfamily members seeking information regarding the victims.
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Part V Long-Term Response and Recovery
Completion of the response to and recovery from a chemical incident will be an extensive
and drawn out effort. A well-prepared and organized response to such an event will be the
catalyst to a rapid recovery and return to normalcy for a city. The integration of federal
assets may be necessary to mitigate long-term medical care of casualties, financial and
social recovery, and the ongoing criminal investigation before eventual return to local
control is possible.
This section outlines important issues surrounding the long-term recovery process for a
community. It provides insight on recovery from the immediate and long-term effects of
an attack and care for those affected.
General
Issue: Employee Assistance Programs
Healthcare providers may experience long-term effects from having to manage the over-
whelming task of a CW terrorist attack. Many personnel will be affected and perhaps have
difficulty performing their jobs, even after receiving Critical Incident Stress Debriefing
(CISD) therapy. Employee Assistance Programs (EAPs) need to be notified, since they
play a part in the long-term recovery of their personnel.
Recommendation.
Personnel should go through CISD as soon as possible. If the agency
EAP is not prepared to initiate CISD, then an outside agency should be called for support.
The International Federation of Critical Incident Stress Debriefing developed by Jeffery
Mitchell, Ph.D. and George Everley, M.D., can be contacted for further recommendations.
EAPs should be prepared to respond to their employees' needs based on the circumstances
of the CW incident and what role their facility played in the overall operation.
Emergency Response
Issue: Replacement of Contaminated Equipment
Replacing contaminated equipment after a CW incident will be a critical concern for all
departments. Verification that equipment is clean is expected to be a major task. It cannot
Considering the serious nature and potential consequences of any terrorist incident, the
Panel is convinced that comprehensive public education and information programs
must be developed, programs that will provide straight-forward, timely information and
advice both prior to any terrorist incident and in the immediate aftermath of any attack
First Annual Report to The President and The Congress of the Advisory Panel to Assess
Domestic Response Capabilities for Terrorism Involving Weapons of Mass Destruction.
RAND 1999, Washington D.C..
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Contamination of response equip-
ment is a concern for all communi-
ties. The need exists to continue to
provide emergency services regard-
less of the impact from the event.
be assumed that equipment will be cleared for return to service in an expedient manner, if
at all. Expeditious temporary or permanent replacement is paramount to provide service
for the community's daily needs.
Recommendation.
The need for replacing contaminated
equipment must be a top priority to continue service to the
community.
Purchase of emergency apparatus can cause a tremendous
financial impact on any department. Departments should
investigate and be familiar with the procedures necessary for
reimbursement once a federal disaster is declared. Other
alternatives include emergency assistance programs offered
by various dealers and manufacturers.
Law Enforcement
Issue: Long-Term Scene Security
A WMD event is expected to initially cover a large operating area. The attack venue,
which may include a large gathering area (e.g., sporting event), use of multiple agent
dissemination points, and an airborne contamination threat are factors relating to the initial
size of the incident scene. As the incident is controlled and hazards are mitigated, the size
of both the response and crime scene will be reduced. Based on the chemical agent used,
the area immediately surrounding the dissemination point may remain contaminated.
Processing of the scene is expected to be an extensive operation, and access to the incident
site will have to be controlled throughout the process.
Recommendation.
Initial scene security will be a manpower intensive operation for law
enforcement. Controlled ingress and egress must be closely coordinated with the fire
department and EOC. Investigation of the scene and possible long-term contamination
hazards could require security for an extensive period of time. As the size of the controlled
area is reduced and the extent of the crime scene determined, law enforcement is expected
to turn to a more fixed type of security as a method of access control. This includes
temporary fencing around the crime scene with controlled access gates.
In addition to the standard controlled access for a crime scene, law enforcement and/or
scene safety officials may be required to monitor personnel entering the area for proper
protective equipment and to ensure that decontamination is conducted prior to departure.Issue: Contaminated Equipment Monitoring
The fact that law enforcement equipment may become contaminated and require
decontamination is discussed in Part IV of this document. Monitoring of decontaminatedequipment and material, however, is considered the final step to the process. Only after
verification that all agent has been removed or neutralized can it be determined safe to
return equipment to service.
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Recommendation.
Departments should coordinate monitoring
their equipment through the emergency management office. The
level of monitoring and type of detector should be coordinated by
the community following advice from various federal agencies
including, but not limited to, the Department of Defense (DoD),
EPA, and OSHA.
It is important that supervisors know that thorough (low-level)
monitoring is resource-intensive costly and time consuming.
Although the resources will most likely be made available through
federal agencies, departments may have to operate without their
equipment for a considerable period of time (several days or more,
depending on the amount of equipment requiring monitoring and
the availability of resources). Equipment can include everything from vehicles and
firearms to individual officer protective gear such as their ballistic vests. Departments
must look at how they will continue to provide support and respond to the community
during this time.
Equipment that is contaminated and unable to be decontaminated to a safe level will have
to be destroyed. Funds for replacement equipment may have to be processed through
federal grant channels, which will be a time consuming process.
Health and Safety
Issue: Fatality Management at the Scene
Medical Examiners face three primary differences from their normal operating procedures
when handling contaminated remains from a chemical terrorist incident.
*
Medical examiners may need to wear PPE to operate within the Hot Zone as well as
when handling contaminated remains or personal effects.
*
Medical examiners will need to gather evidence before remains are decontaminated.
This means that the medical examiner must perform external evaluations at the incident
site.
*
*
Remains must be decontaminated at the incident site before they are moved to another
location to minimize as much cross-contamination as possible.
Recommendation.
Wearing PPE.
Despite not having the training or equipment to enter a
Hot Zone, medical examiners are not relinquished of their duties to manage fatalities from
a chemically contaminated incident. Though other agencies like the FBI and DMORT are
able to support fatality management efforts under specific circumstances, they are not able
to perform all the duties a medical examiner is expected to perform.
All ME/C personnel do not need to be prepared to enter a Hot Zone in Level-A PPE.
Recovery of remains may occur hours, if not a day or two, after the initial incident.
Low-level monitoring will
most likely only be avail-
able through federal re-
sponse agencies.
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Hazardous waste products may not be nearly as concentrated at this point in time, thereby
requiring a reduced level of PPE. The medical examiner should coordinate with the IC as
to the level of PPE required at the time of their entry.
Medical examiner's should train and equip a specialized team to wear Level A PPE. At
least four individuals should be able to enter a Hot Zone, whereas the rest of the medical
examiner personnel only need to perform their tasks in Level C PPE. The two teams of
individuals wearing Level A should evaluate the scene to determine manpower and
resource needs to process remains.
Gathering Evidence.
The medical examiner should establish an evaluation team that can
enter a Hot Zone with the lead-investigating agency to determine how to best process the
crime scene and how to process remains. All regional FBI offices have a WMD
Coordinator capable of entering the Hot Zone. Additionally the FBI has one special team
called the Hazardous Materials Response Unit (HMRU) that is equipped to collect
evidence inside the Hot Zone. If both agencies are equipped to enter the crime scene then
collectively they can determine the joint investigation procedures needed to process the
scene. The medical examiner must, perform external evaluations and gather personal
effects at the incident site, prior to decontamination efforts.Gross Decontamination.All remains must be grossly decontaminated before they are
removed from the scene to minimize cross-contamination.
Gross Decontamination efforts begin with the removal of clothing and flushing of the bodywith water. It is recommended that medical examiners perform a gross decontamination onscene followed by a detailed decontamination prior to processing the body at the morgue.The scene may already have decontamination lines that were established for live patientsthat can be used to process the remains. Decontamination studies indicate the following:*
Water alone is an excellent decontamination solution.*
Adding soap aids in dissolving oily substances like mustard or blister agent.
*
Bleach (sodium hypochlorite) and water solution remove, hydrolyze, and neutralize
most chemical agents.
* Note:
Studies conducted by the U.S. Army Mortuary Affairs Center determined that a
low concentration of bleach 2 to 3 percent did not present any negative effects (e.g., loss of
color or damage to skin) to remains. Higher concentrations, such as straight household
bleach (5.25 percent) were not tested, but it is believed that they would have a negative
impact on tissue.
The medical examiner should establish an agreement with an agency that is equipped to
establish a decontamination line, is capable of operating in PPE, is familiar withdecontamination procedures, and has the manpower and equipment necessary to performthe operation. When requesting such assistance, consideration must be given to the
mission being performed. Although many jurisdictional agencies may have the ability to
perform gross decontamination, their organization may not be inclined to decontaminatehuman remains.
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Contamination issues change the
standard procedures for processing
remains.
Also of importance is the issue of contaminated water runoff. The EPA issued a decision
indicating that mitigating water runoff should not take precedence over performing life-
saving measures. This may not extend to processing the deceased. The medical examiner
must therefore ensure that there is a system in place to contain water runoff before
decontamination is initiated.Issue: Fatality Management at the Medical Examiner's Office
Managing a mass number of fatalities from a chemical
terrorist attack changes the normal procedure for processing
remains.
Tracking remains is complicated because remains mustundergo decontamination before they are removed from theincident site. Some EMS jurisdictions already use a
waterproof tag with peel-off stickers relating to the triage tag
number or bar codes. Exercises conducted by the CWIRP
using some of these tags have indicted additional problems
still exist with their use. The tags hold up well when wet, but
it is almost impossible to write on them afterward. Also, the peel-off stickers don't adhere
well after being wet. Additionally, tagging methods that are used by EMS and those used
by the medical examiner are not always compatible.
The number of fatalities may influence the type of transportation needed to move remains
from the incident site to a temporary morgue or autopsy area. Typically, storage areas at an
medical examiner's office do not provide adequate space, and it is preferred that the
remains from the same incident be centrally located.
The length of time needed to process remains will be extended because this is a chemical
incident. Influencing factors include the number of fatalities involved, decontaminationrequirements, and the need to process remains in PPE.
Recommendation.
Since remains must be decontaminated before they are moved from
the incident site, tracking a large number of chemically contaminated fatalities is madeeasier with a waterproof tag. If manufacturers resolve the above drawbacks, the general
concept provides a clear advantage to the agencies involved with processing victims and
fatalities. Peel-off stickers are easy methods to rapidly account for personal belongings and
paperwork associated with the remains. Bar code scanners also simplify the
recording/tracking process because they are portable and can be used in the field.Refrigerating remains is the optimal means of storage, since it gives the medical examiner
additional time to process remains while mitigating any public health hazard. Depending
on the number of fatalities, however, normal refrigerated storage units may not be able to
accommodate the needs. As an alternative storage site, refrigerated trucks and/or rail cars
can be used for storage as well as transportation. To ease handling, remains should not be
stacked unless shelving units are used. Even with shelving units, it is recommended that
remains not be stacked above waist level to accommodate those handling the remains.
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Typically, a railroad car can accommodate 32 to 40 bodies in this manner (Military
Planning for Health Services Support, 1994).
Other locations should be identified early as potential storage locations. Possible locations
include the state anatomy board and/or small buildings or rooms that can be cooled to
35
°
F. Other options include obtaining air conditioning units that can cool a large room or
small building to 35
°
F. Further consideration when identifying storage locations is that
the area must be secured by law enforcement personnel until they release the body as part
of the investigation.
Some jurisdictions have the capability of embalming a mass number of remains quickly.
Incorporating embalming into the disaster response plan may simplify decisions regarding
final disposition. The benefits of embalming include the following:
*
Remains can be held for a longer period of time while evidence is gathered.
*
Refrigeration units are necessary only for those remains identified for autopsy.
*
A higher level of safety is ensured if remains are decontaminated twice, embalmed, and
undergo a final rinse so that decontamination demands are not passed to localmorticians.
*
Embalming provides a 7- to 10-day opportunity for an open casket viewing, and it
provides a 2- to 3-week window of time before refrigeration becomes necessary.
The size of the incident may dictate the use of a temporary morgue site and/or a temporary
autopsy area. Many medical examiner offices currently have plans developed to perform
operations outside their facility if they are forced to evacuate the building. Medical
examiners can use these evacuation plans as a starting point in establishing a temporary
operation area in response to a disaster.
In terrorist situations, the FBI must gather as much evidence as possible to prosecute the
case. Unfortunately, when the number of fatalities goes beyond a medical examiner's
annual caseload, the medical examiner's office may face a code 2 license violation.
Additionally, it may be impractical to perform autopsies on all remains (to perform 200
autopsies would require 52 medical examiners and more than 2 weeks to complete).
Although all remains should have an external examination, the medical examiner and the