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Chapter 6
Metropolis, USA: Progress, Pitfalls in Front-line Readiness
Amy E. Smithson
Ask public safety officers, rescuers, health care providers, and city emergency managers what their
challenges would be in the aftermath of a chemical terrorist attack and at a staccato pace they start
ticking problems off on their fingers. Absence of awareness and standard operating procedures in 911 call
centers. Disinterest among the police, who are insufficiently equipped and trained and therefore likely to
rush into trouble. Difficulty in decontaminating large numbers of casualties rapidly. Lack of chemical
antidotes, not to mention uncertainty about the protocols to administer them. Far too few hospitals ready to
handle a major onrush of panicked, possibly contaminated casualties. Inadequate chemical casualty care
training among medical professionals, not just in the emergency departments but throughout the hospitals.
Deficiencies in communication systems likely to be overwhelmed and therefore contribute to a confused
response. They run out of fingers before they reach the challenges of recovery in the days and months after
such an attack. The list of worries deviates slightly from city to city, and although they have made headway
in some areas, even cities that have benefitted from assistance under the federal government's unconventional
terrorism preparedness programs can identify gaps in their planning and capabilities to deal with a large-scale
chemical incident.
When these same individuals are asked to assess their level of readiness before and after receiving
aid via one or more of the preparedness training and equipment programs, the answers also vary from city
to city as well as among response disciplines. For example, in cities where the local government chipped
in financial support for adequate manpower to enhance response plans and propagate the training, the ratings
tended to be higher. Also, the training and equipment programs centered around firefighters and hazardous
materials (hazmat) personnel, who generally gave higher ratings. Even within the firefighting ranks,
however, some gave low assessments after the federal assistance. One fire chief said that "the training done
to date has scared the first responders so much that they will stand back and watch people die."1 As a whole,
the appraisals of health care providers tended to be lower, since much less of the federal planning, training,
1 Continued the chief, "They don't feel equipped either with the training or gear to tackle the situation." Interview with
author: Chief, County Fire Department (9 September 1999). Also on this point: Hazmat Coordinator/Instructor (8 September
2000); Police Lieutenant (23 March 1999). Note also that one battalion fire chief lowered his city's chemical and biological
preparedness rating three and two points, respectively, after the training, saying that he thought they were prepared before but
now saw the magnitude of the problem differently. Interview with author: Battalion Fire Chief, Special Operations (25 May
2000).
202 Ataxia: The Chemical and Biological Terrorist Threat and the US Response
and equipment assistance reached the medical sector. Of the preparedness of health care givers, a local
official simply noted, "We've got problems no matter where we look."2
The responders' assessments were subjective, since they were working without a definition of what
constitutes "preparedness." While some local officials felt qualified to appraise only their own organization's
status, others had a broader view of activities city-wide and therefore felt comfortable rating their city as a
whole. Although the ratings in figure 6.1 are something of a potpourri, the intent of the survey was not to
obtain a discipline-specific measure of preparedness. Rather, the purpose was to gain a sense of whether the
federal programs were making a difference locally and how far along the path to readiness various local
officials believed their cities to be. The proposed rating scale was from one to ten, with one being the least
prepared and ten the most. For the "before" ratings, several local officials rewrote the scale. Five specified
that their city ranked a zero and one a negative five prior to the federal aid programs. Overall, the local self-
ratings certainly marked improvement, with the "before" ratings averaging 3.1 and the "after" score rising
to 5.9. The mean improvement was 2.8. Eventually, almost all local officials ended up commenting on the
unescapable, however. The level of preparedness in the months immediately following the federal programs
might not be there in the years ahead unless training is institutionalized, equipment maintained, and seldom-
used skills are drilled.3
Working from interviews with front-line personnel, the first half of this chapter describes what would
unfold in a large US city stricken by a terrorist attack involving a chemical agent. The latter half provides
a similar description for a likely response to a bioterrorist attack. This text can function at several levels.
First, congressional, federal, and local officials can gain insight into where the front line is having difficulty
with response capabilities, serving as a guidepost so that the appropriate adjustments to federal and local
efforts can be made to address these gaps. Second, local emergency response officials may find a number
of ideas that have been employed in other locations that would improve their plans and strategies. Finally,
the following pages can provide lay readers and the media a reasonable understanding of the significant
challenges facing on-scene rescuers and health care providers who would attempt to help their fellow citizens
after this type of disaster.
2 Interview with author: Paramedic/Emergency Planner, Public Health Department (4 February 1999). Also, "Heaven
forbid something happens tomorrow, we're definitely not ready." Interview with author: Registered Nurse/Hospital Disaster
Coordinator (4 February 1999). Similar remarks were made by a physician from a city that viewed preparedness as being much
better than elsewhere. Interview with author: Physician, Hospital Department of Emergency Medicine (24 March 1999).
3 Conveying this point of view: "Sure, the feds gave us a bunch of equipment, but that does not mean we're ready now
or that we'll be ready in the future." Interview with author: Special Projects Program Manager, Department of Public Health (5
February 1999).
Chapter 6 Metropolis, USA: Progress, Pitfalls in Front-line Readiness 203
Figure 6.1: Local Officials Assess Their Preparedness for a Large-Scale Chemical Terrorist Event*
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Before After
*Not all local officials interviewed for this report were asked to rate themselves and some who were asked declined to do so. The survey
includes the appraisals of responders from twenty-two cities, although interviews were conducted with over thirty cities. Some responders
were from cities that at the time of the interview had received only the Domestic Preparedness Program training, and others were from
cities also enrolled in the Metropolitan Medical Response System program. Some cities had received equipment grants from the Justice
Department, others had not.
Sources: Interviews with author: General Manager, Emergency Department (22 September 2000); EMS Chief, Emergency Services Department (21
September 2000); Director, County Emergency Management (21 September 2000); Physician/University Hospital Department of Emergency Medicine (20
September 2000). Physician, Director of Health, Public Health Department (20 September 2000); Director, Emergency Management Division, County
Department of Public Safety (19 September 2000); Director, Office of Emergency Preparedness (19 September 2000); Police Lieutenant, Tactical Support
Office (18 September 2000); Hazmat Coordinator/Instructor (8 September 2000); Fire EMS statistician (30 August 2000); Emergency Planner, Hospital
Health Maintenance Organization (15 August 2000); Police Lieutenant (8 July 2000); Medical Toxicologist/Poison Control Center Director (13 June 2000);
Physician, Hospital Division of Emergency Medicine (31 May 2000); Deputy Director, Office of Emergency Management (26 May 2000); Battalion Fire
Chief, Special Operations (25 May 2000); Director, Emergency Services Department (18 May 2000); Emergency Management Specialist, Office of
Emergency Management (9 May 2000); Police Sergeant (9 May 2000); MMRS Coordinator, Fire Department (9 May 2000); Registered Nurse/Emergency
Planner, Public Health Department (7 April 2000); Registered Nurse/Chief, EMS Division, State Department of Public Health (3 February 2000); Deputy
Coordinator, Fire Emergency Preparedness and Disaster Services (3 February 2000); Detective/Bomb Squad (19 January 2000); Project Manager,
Emergency Management Planning (27 July 1999); Director of Hospital EMS and Disaster Medicine (19 April 1999); Fire Commander (19 April 1999);
Toxicologist, Poison Control Center (9 March 1999); Emergency Planner, Office of Emergency Management (8 March 1999); District Fire Chief, EMS
Division (2 March 2000); Police Captain/Firing Range Director (5 February 1999); Emergency Response Planner, Office of Emergency Management (5
February 1999); Captain/Assistant Emergency Management Coordinator (5 January 2000); Battalion Fire Chief (17 November 1999); Battalion Fire
Chief/Emergency Services Administrator (15 November 1999); Battalion Fire Chief (15 November 1999); Associate Hospital Administrator/Registered
Nurse (13 November 1999); EMS Superintendent-in-Chief (24 March 1999); Physician, Hospital Department of Emergency Medicine (24 March 1999);
Police Commander, Special Operations Division (23 March 1999); Assistant Director, Office of Emergency Management (23 March 1999); Deputy Fire
Chief (23 March 1999); Police Captain, Special Operations Division (23 March 1999); Lieutenant/Hazmat Commander (10 March 1999);
Physician/Associate Director, Hospital Department of Emergency Medicine (9 March 1999); Paramedic Operations Supervisor (9 March 1999); Fire
Captain, HazMat Unit (9 February 1999); Emergency Preparedness Director, Office of Emergency Services (9 February 1999); Battalion Fire Chief (9
February 1999); Fire Battalion Chief/Hazmat Specialist (8 February 1999); Police Lieutenant (8 February 1999); Battalion Fire Chief/EMS Supervisor (8
February 1999); Police Captain, Special Operations Division (8 February 1999); Special Projects Program Manager, Department of Public Health (5
February 1999); Fire Lieutenant (5 February 1999); Paramedic/Emergency Planner, Public Health Department (4 February 1999); Director, Office of
Emergency Services (4 February 1999) Registered Nurse/Hospital Disaster Coordinator (4 February 1999).
204 Ataxia: The Chemical and Biological Terrorist Threat and the US Response
BUILDING BLOCKS FOR RESPONDING TO TERRORIST INCIDENTS
No matter how well-equipped and trained the emergency rescuers in a community are, the
effectiveness of the different responding agencies, separately and together, would be degraded if they do not
have agreed upon disaster response plans. In a great many cities, a flexible, "all-hazards" plan already exists
that, with situational adjustments, can apply to this kind of disaster.4 So, communities need not start from
scratch, because they already have mechanisms in place (e.g., state emergency response plans, hospital mass
casualty plans) that can serve as a planning platform. Many metropolitan areas created a terrorism
subcommittee within an existing planning group to assess local risks and capabilities to handle the
extraordinary circumstances that a chemical or biological terrorist event would create. The end product was
an annex to existing multi-disaster plans and a prioritization of needed response improvements.5
One entity that might be assigned the task of unconventional terrorism response planning is the Local
Emergency Planning Commission, which is responsible for formulating a community's disaster response plan
for hazmat incidents that must be drilled annually.6 In important respects, a chemical terrorist attack would
be an amplified hazmat incident. Commission members are already well-versed in local hazmat response
capabilities, not to mention the number, location, and nature of hazmat sites in the area. Substances that pose
a danger to human health and the environment can be found in abundance in US cities.7 Since terrorists
4 Howard Levitin, "Preparing for Terrorism: What Every Manager Needs to Know," Public Management 80, no. 12
(December 1998): 78.
5 One county accomplished this planning, tailored training, and exercising for first responders under a $65,000 grant
from state government. Their capability assessment covered ability to identify the agent involved, control access to the site,
predict plume and downwind effects, maintain secure communications, protect first responders, alert response entities, gather
intelligence, evacuate the public or shelter them in place, decontaminate victims, care for large numbers of casualties, and
communicate necessary information to the public. Interviews with author: Director, County Emergency Management (21
September 2000); Deputy Director, Office of Emergency Management (2 March 2000). On the utility of building from existing
plans, interviews with author: Director, Emergency Management Division, County Department of Public Safety (19 September
2000); Battalion Fire Chief, Special Operations (25 May 2000); MMRS Coordinator, Fire Department (9 May 2000); Police
Captain (10 August 1999); Physician, Hospital Division of Emergency Medicine (6 August 1999); Project Manager, Emergency
Management Planning, Office of Emergency Management (27 July 1999).
6 Passed by Congress on 17 October 1986, the 1986 Superfund Amendment Reauthorization Act mandated that state
governments appoint members to these commissions, including state and local government officials, representatives from police
and fire departments, environmental, public health, transportation and civil defense agencies, hospitals, community groups, and
the media. Each commission's primary responsibility is the development and maintenance of an emergency response plan for
potential chemical accidents that is specific to local conditions. Since the original legislation did not provide funds for the
commissions, resources to sustain their activities are borne at the local level, which means that commissions are much more
active in some areas than in others. See Public Law 99-499, Title 3. Under section 302 of Title 3, chemical companies and other
industries that consume, handle, store, or process hazardous substances are required to submit data to these panels annually on
the amount of hazmat chemical(s) on sites and where they are located. Also, Occupational Safety and Health Administration
(OSHA) regulation 1910.120 requires employers to set up a health and safety plan dealing specifically with hazmat emergencies,
including the training of personnel, establishment of fire brigades, and designation of escape routes.
7 One emergency official said that his city had over four hundred facilities working with extremely hazardous
substances and over two thousand regular hazmat facilities. Another said that there were roughly six thousand laboratories in his
city using hazardous materials, as well as several high-level containment laboratories working with dangerous pathogens. Yet a
Chapter 6 Metropolis, USA: Progress, Pitfalls in Front-line Readiness 205
could well view hazmat sites as an attractive target for theft or sabotage, some communities worked through
these planning commissions and public safety authorities to strengthen the security at hazmat facilities.8
Another city identified some two thousand locations of all types that could benefit from a security
consultation and activated an expert team for that purpose.9
Another important step that metropolitan areas can take to facilitate a prompt and organized response
is to prepare contingency plans for major sites. To create such a plan, an emergency response team first
surveys the location, whether it be a sporting arena, office building, civic auditorium, landmark, amusement
or public park, zoo, shopping mall, or transportation center. They identify optimum area(s) at the site for
rescuers to enter swiftly, to set up a command post, to gather, decontaminate, and triage casualties, and to
stage emergency equipment. The best routes to and from to the closest trauma center and other hospitals are
marked. At large indoor facilities, this team also scouts the ventilation system and obtains the telephone
numbers for the site engineer or others who would be able to advise them on its operation. Then, the
emergency responders meet with the managers of the site to discuss the plans and ascertain what logistic
support the facility might make available during an emergency. Some site managers agree to drill the plan.
Some cities drew up contingency plans for their major sites long ago, with natural disasters, fires, or
conventional bombings in mind.10
The domestic preparedness effort prompted other cities to identify their high-risk facilities and map
out contingency plans. Aside from major public gathering places, some cities have taken extra precautions
third recalled over three hundred such facilities within city boundaries, including over 125 extremely hazardous substance sites.
Interviews with author: Deputy Director, Office of Emergency Management (26 May 2000); Fire Chief (15 May 2000); Deputy
Coordinator, Fire Emergency Preparedness and Disaster Services (3 February 2000).
8 Interviews with author: MMRS Coordinator, Fire Department (9 May 2000); EMS System Analyst/Paramedic, State
Department of Health and Social Services (25 January 2000); Lieutenant/Hazmat Commander (10 March 1999). OSHA
regulation 1910.120, which governs emergency response plans at hazmat facilities, stipulates that a facility's plans address "site
security and control," but this matter receives neither emphasis nor exposition within the text of the regulation. Matters such as
the height of security fences, creation of patrols, and other measures to prevent or restrict access are left to the judgment of the
facility operator.
9 The local Federal Bureau of Investigation (FBI) office in this city has organized a small team of fire, bomb, and
special weapons and tactics specialists. In addition to the factors considered for an emergency response contingency plan, this
team looks at a site's security patrol patterns and incident response plans. Afterwards, the team makes verbal recommendations
to site security and managerial personnel on how to harden the facility against intruders. Within a five-month period, this team
completed almost ninety consultations. Interview with author: FBI Special Agent (3 February 2000).
10 City officials are confident that these plans would serve well in an unconventional terrorist attack. Interviews with
author: Director, County Emergency Management (21 September 2000); Battalion Fire Chief/Special Operations Officer (25
May 2000); Emergency Management Specialist, Office of Emergency Management (9 May 2000); MMRS Coordinator, Fire
Department (9 May 2000); District Fire Chief, EMS Division (2 March 2000); Deputy Fire Coordinator, Emergency
Preparedness and Disaster Services (3 February 2000); Battalion Fire Chief, (19 January 2000); Lieutenant/Hazmat Operations,
Fire Department, (27 July 1999); Fire Chief (6 April 1999); Deputy Fire Chief (23 March 1999); Emergency Preparedness
Director, Office of Emergency Services (9 February 1999).
206 Ataxia: The Chemical and Biological Terrorist Threat and the US Response
with other high-risk sites (e.g., government buildings, Planned Parenthood clinics).11 These sites
disproportionately receive threats of all types. As noted in chapter 2, the incidents involving chemical and
biological substances were mostly non-credible threats, but some have resulted in minor injuries from
materials like butyric acid.12
LOCAL BLUEPRINTS FOR RESPONDING TO A
CHEMICAL TERRORIST ATTACK
Getting A Smart Start
When a noxious substance is in the air, it often creates victims and panic. Emergency responders
increasingly understand that after a chemical terrorist attack they would encounter chaos and could
themselves be overcome by toxic fumes. Since 911 calls often bring police to the scene moments before
firefighters, police have been nicknamed the "blue canaries." This label is a macabre reference to the fact
that soldiers and miners used to carry the caged yellow birds to detect the presence of poison gases. The
number of first responders injured would depend largely upon any warning they might get en route and their
training and awareness of the consequences of chemical agent exposure.13
Time and again, the importance of how 911 call receivers and dispatchers handle their duties has
been demonstrated. Emergency call receivers ascertain the scope of an emergency and whether its cause is
readily understood (e.g., gunshot, explosion), and, accordingly, forewarn rescuers when extra caution should
be used. The alertness of 911 call receivers and dispatchers to the signals of a toxic event would therefore
11 Cities applying for a Justice Department equipment grant are required to conduct an analysis of all of their high-risk
sites. In addition to preparing contingency plans for these sites, one city sent the terrorism awareness tapes to all of the sites on
its list. Interviews with author: Battalion Fire Chief, Special Operations (25 May 2000); Fire Commander (19 April 1999).
12 On the preponderance of hoaxes, see the end of chapter 2. Also, Paul de Armond, "Right Wing Terrorism and
Weapons of Mass Destruction: Motives, Strategies and Movements," in Hype or Reality? The "New Terrorism" and Mass
Casualty Attacks, ed. Brad Roberts (Alexandria, Va.: Chemical and Biological Arms Control Institute, 2000); T. Trent Gegax and
Mark Hosenball, "The New Bomb Threat," Newsweek, 22 March 1999, 36; Jason Pate, Center for Nonproliferation Studies,
Monterey Institute for International Studies, "Anthrax Hoaxes in the United States," forthcoming 2001.
13 Police are not the only first responders likely to rush in and be injured in such circumstances. One city conducted a
no-notice, mass casualty drill fifteen years ago mocking the release of an organophosphate chemical. Exercise officials ruled the
first fire engine and EMS companies to arrive "dead" of exposure to the hazardous material. Interview with author:
Physician/Associate Director, Hospital Department of Emergency Medicine (9 March 1999). Theoretically, firefighters are better
equipped and trained to cope with this situation since they have self-contained breathing apparatus. However, firefighters also
took considerable "casualties" in a drill mocking the release of sarin in New York City's subway system in June 1995. The
author has reviewed the videotape of this exercise, conducted at the station located at East 14th Street and 1st Avenue. Interviews
with author: former EMS Supervisor/Paramedic (12 July 2000); Project Manager, Emergency Management Planning, Office of
Emergency Management (27 July 1999). In the 20 March 1995 sarin attack in Tokyo, roughly 10 percent of the first responders
were injured, although none seriously. For more detail, see chapter 3.
Chapter 6 Metropolis, USA: Progress, Pitfalls in Front-line Readiness 207
be a crucial factor in limiting injuries among the first rescuers.14 One veteran firefighter described the 911
dispatcher as "the most important person there is in an unconventional terrorist event" because that person's
quick thinking could save the lives of victims and responders alike.15 Nonetheless, the domestic preparedness
training touched lightly on the role of the 911 centers.16 Figure 6.2 diagrams one city's 911 protocol.
Should a caller report numerous choking, seizing victims, a properly trained 911 dispatcher would
advise the police, fire, and Emergency Medical Service (EMS) units directed to the site of a possible toxic
hazard. Next, the dispatcher would follow standard operating procedures, proceeding down a call list to roll
out other units that may be required, particularly the hazmat team.17 In other words, 911 operators could get
a response off to a smart start. For the time being, however, in many cities rescuers could arrive at an
incident scene with minimal warning and information because 911 staffs have not consistently received
tailored training or standard operating procedures.18
14 The rule of thumb is that one or two people down may be suffering heart attacks or seizures, but any time there are
multiple casualties on the ground for unclear reasons, an unknown gas present may be present. Interviews with author: Deputy
Director, Office of Emergency Management (27 July 1999); Police Commander and Police Captain, Special Operations Division
(23 March 1999); Battalion Fire Chief (8 February 1999). One state has drafted a pocket guide that is aboard all of its first
response units and enumerates the steps to be taken in such circumstances. Interview with author: Captain, State Highway Patrol
(22 April 1999).
15 Interview with author: Fire Captain/Assistant Emergency Management Coordinator (5 January 2000). Seconding the
importance of well-trained dispatchers: Director, Emergency Management Division, County Department of Public Safety (19
September 2000).
16 The manual's broad instructions are that the operators and dispatchers need to recognize verbal descriptions of an
attack and unusual trends, know what questions to ask, alert the appropriate responders, and provide them with safety guidance.
"Responder Actions," in Domestic Preparedness Training: Responder Awareness Course, Instructor Guide, Booz Allen &
Hamilton Inc., Science Applications International Corporation, EAI Inc., and Disaster Planning International, Inc. (1998), 30.
17 Given the prevalence of toxic hoaxes over the past couple of years, 911 staff should also have standard operational
procedures for toxic threats. One city dispatches a police car and supervisor to the scene, notifying the fire department and FBI
of the situation. If the initial responders locate a device, the bomb squad is called, the on-scene command is turned over to the
hazmat chief, and the fire chief is informed of the situation. Interviews with author: Police Commander and Police Captain,
Special Operations Division (23 March 1999). When an untrained dispatcher at one 911 center took a call about the receipt of a
letter supposedly containing anthrax, both the dispatcher and the supervisor gave the call a routine priority. The responding
police officer, also untrained and unfamiliar with anthrax, became a "victim." Afterwards, emergency officials concluded that
everyone in the response chain needed awareness training, standardized notifications, appropriate response assets identified
beforehand, and clearly delineated agency responsibilities. Interview with author: Fire Chief (6 April 1999). When an anthrax
hoax letter ended up in Phoenix, the rescuers' response terrified the victims, cost the company involved $43,000 in lost
productivity, and ran the city $40,000 for police, fire, and laboratory testing. Kerry Fehr-Snyder, "It Was a Day I Will Never
Forget," Arizona Republic, 15 February 2000. The problem of "overresponding" is also discussed in chapter 2, footnote 181.
18 As noted in chapter 5, just under half of the respondents answered negative when asked if their 911 personnel had
been trained. Moreover, such training does not ensure that 911 operators will handle this type of incident well. In one city, just
a week after 911 dispatchers and their supervisors received awareness training, a caller reported over a dozen casualties and an
unknown gas in a shipping mall, but the 911 dispatcher did not call the hazmat unit or warn responding paramedics of the
possible presence of a toxic substance. Interview with author: Paramedic Operations Supervisor (9 March 1999).
Figure 6.2: Example 911 Protocol for a Mass Casualty Incident Involving Hazardous Materials
CALL TAKER RESPONSIBILITIES KEY QUESTIONS TO ASK CALLER
* Ask series of specific questions about the nature of the incident -What type of facility is involved?
* Instruct caller to: -How many people are involved?
-leave product where it is to prevent further contamination -What are their signs and symptoms?
-evacuate immediate area -What type of substance is involved (e.g., gas, liquid)?
* Dispatch a first alarm plus hazmat response, going to a tactical channel -Where in the structure is the substance?
and forwarding details from caller and advising of possible nuclear, -Was anything unusual seen happening?
biological, chemical/mass casualty incident -What are the surroundings?
-Are any odd packages, containers, or bottles in the area?
-What do they look like?
-Are there any pools of liquid or powder on the ground?
-Are there any clouds or fog?
-Was there an abnormal smell? What did it smell like?
FIRST ALARM HAZMAT REQUIREMENTS -Was anyone using a spray device?
* 2 pumpers -Is there a fire or was there an explosion?
* 1 ladder -Was the caller exposed to the substance?
* 2 rescues -Are there any dead animals, birds, or insects?
* All hazmat -Where can rescuers meet the caller?
* 2 battalion chiefs
* Decontamination assistance from other units
* Activate mutual aid hazmat team
CHIEF DISPATCHER RESPONSIBILITIES
* Activate MMST and request personnel to respond or contact dispatch
* Make appropriate fire department notifications
* Contact fire department public information officer for media alert
* Advise ambulance service of incident and potential resource needs
* Notify Red Cross and/or Salvation Army
* Arrange for food and shelter for victims and emergency workers
DISPATCH OPERATIONAL ADJUSTMENTS
* Isolate tactical channel
* Clear additional channels for use IF EMERGENCY OPERATIONS CENTER
* Activate call for all staff chiefs to respond for support ACTIVATED
* Call out additional dispatch staff * Assign callback supervisor and a dispatcher to
* Prepare for emergency operations center activation emergency operations center
* Provide personnel for dedicated customer service coverage * Once operational, transfer tactical radio operations
* Request additional public information assistance to emergency operations center to free up
* Bring in additional communications staff to maintain regional dispatch for other calls
coverage, activate emergency deployment procedures, and * Bring in additional dispatch support as needed
possibly call back field personnel
Source: City Fire Department, Dispatch and Deployment Procedures Protocol (June 1999).
Chapter 6 Metropolis, USA: Progress, Pitfalls in Front-line Readiness 209
Beginning to Wrest Order From Chaos
As the closest rescue units arrive on the scene, responders might observe important signs of a toxic
threat, such as dead birds and other small animals, not just choking people. To avoid becoming victims
themselves, the initial rescuers may decide that their best course of action would be to withdraw and call for
units properly equipped to operate in a toxic environment. Circumstances would dictate whether front-line
units could and should attempt rescue operations.
Once the general nature of the emergency is recognized, the senior fire or hazmat officer on the scene
would probably assume command responsibility until all victims who can be rescued are saved. The incident
commander would bear the burden of making a series of critical decisions in rapid-fire succession.19 This
individual's first priority would be to figure out how to keep things from getting worse, so he must quickly
size up the situation, taking into consideration the type of venue and estimating how many people were
harmed.20 As a matter of priority, he would request the city's hazmat squad, of which there are some six
hundred across the country.21 If a city had a Metropolitan Medical Response System (MMRS) team, this unit
and any inventory of personal protective gear and specialized detection, decontamination, and rescue
equipment would also be called to the scene, along with bomb and special weapons and tactics (SWAT)
teams.22 In the interim, the incident commander would begin examining the bare-bones options of how to
rescue victims. Initial rescue decisions would be driven by the number of moving, viable victims and how
quickly additional personnel and special equipment could get there, among other factors. Within minutes,
responding agencies would establish command posts. Ideally, a unified incident command post collocating
personnel from all responding agencies would form, a safe distance upwind and, if possible, uphill from the
"hot zone," where the toxic hazard might persist.23 As assorted rescuers arrive, the incident commander
19 An incident commander can use one of several decision management systems in this regard, including DECIDE, the
8-Step Process©, GEDAPER©, and HAZMAT Strategic Goals. These managerial tools are summarized in Chris Hawley,
Hazardous Materials Response & Operations (Albany, NY: Delmar, Thomson Learning, 2000), 124.
20 Interviews with author: Hazmat Coordinator/Instructor (8 September 2000); MMRS Coordinator, Fire Department (9
May 2000); Fire Captain/Assistant Emergency Management Coordinator (5 January 2000); Battalion Fire Chief/Emergency
Services Administrator (15 November 1999); Police Commander and Police Captain, Special Operations Division (23 March
1999).
21 General Accounting Office, Combating Terrorism: Use of National Guard Response Teams Is Unclear
GAO/NSIAD-99-110 (Washington, DC: US General Accounting Office, May 1999), 2.
22 Interviews with author: Battalion Fire Chief, Special Operations (25 May 2000); District Fire Chief, EMS Division
(2 March 2000); Fire Captain/Assistant Emergency Management Coordinator (5 January 2000); Deputy Director, Office of
Emergency Management (27 July 1999); Police Commander and Police Captain, Special Operations Division (23 March 1999).
23 Interviews with author: Hazmat Coordinator/Instructor (8 September 2000); MMRS Coordinator, Fire Department (9
May 2000); Fire Captain/Assistant Emergency Management Coordinator (5 January 2000); Battalion Fire Chief/Emergency
Services Administrator (15 November 1999); Police Commander and Police Captain, Special Operations Division (23 March
1999). The bombing of the Murrah Building in Oklahoma City occurred at 9:02am. The shift commander of the fire department
began setting up a command post between 9:05 and 9:08am, a block away from the incident site. Also at 9:08am, emergency
210 Ataxia: The Chemical and Biological Terrorist Threat and the US Response
would ask them to accomplish several tasks simultaneously or in quick succession, as the following
paragraphs describe. After such an attack, these tasks would be very difficult even for well-equipped and
drilled responders.
Hazard Assessment
To identify and assess the concentration of the toxic substance, the incident commander would insert
a small reconnaissance team. Circumstances would determine whether firefighters outfitted in maximum
protective gear-level A-or in self-contained breathing apparatus (SCBA) and taped-down bunker gear
should take on this task.24 The team would activate detectors and take a quick look around, observing the
victims' symptoms and behavior, before withdrawing to brief the incident commander so that an appropriate
response plan could be devised.25
Ideally, this team would be equipped with a combination of detectors to provide a general
characterization of the hazardous threat within moments.26 As noted in chapter 5, some emergency
responders were not confident that they purchased the best detection equipment. Some cities would employ
medical services was establishing a command post on the same street, a block away from the fire command post. Police ordered
their mobile command post to the scene at 9:19am, with the vehicle arriving at the fire command post at 9:31am. Alfred P.
Murrah Federal Building Bombing April 19, 1995: Final Report, The City of Oklahoma City (Stillwater, Okla: Fire Protection
Publications, Oklahoma State University, 1996), 3656.
24 Defense Department-sponsored tests show that turnout gear and SCBA will provide sufficient protection to enter the
hot zone for a time ranging from two to thirty minutes. If an unknown nerve agent or suspected mustard gas is present, taped
down turnout gear with SCBA will protect the wearer for two to three minutes. For this type of insertion, firefighters would use
duct tape to secure their bunker gear at several different places to reduce the possibility of skin exposure to agent. Guidelines for
Mass Casualty Decontamination During a Terrorist Chemical Agent Incident (Aberdeen, Md.: US Army Soldier and Biological
Chemical Command, January 2000), 710.
25A reconnaissance team is not likely to confront any suspected terrorists that remain at the site or to rescue victims
since it could consist of as few as two individuals. Interviews with author: Hazmat Coordinator/Instructor (8 September 2000);
Battalion Fire Chief, Special Operations (25 May 2000); MMRS Coordinator, Fire Department (9 May 2000); Deputy
Coordinator, Fire Emergency Preparedness and Disaster Services (3 February 2000); Police Detective/Bomb Squad member (19
January 2000); Fire Captain/Assistant Emergency Management Coordinator (5 January 2000); Battalion Fire Chief/Emergency
Services Administrator (15 November 1999); Battalion Fire Chief (15 November 1999); Police Commander and Police Captain,
Special Operations Division (23 March 1999).
26 Several types of chemical agent sensors could be employed, including the APD-2000 handheld monitor from
Environmental Technologies; the SAW mini-CAD from Microsensor Systems, Inc; the IQ-1000 multi-gas detector from
International Sensor Technology; and detector tubes from Draeger. These detectors are multi-purpose. For example, the SAW
mini-CAD also detects a few industrial chemicals, and the APD-2000 detects pepper spray and mace. Other detectors purchased
through the federal grant programs included the M256 chemical detection kit from Truetech, Inc. and M-8/M-9 chemical
detection papers from Tradeways, Ltd.
Chapter 6 Metropolis, USA: Progress, Pitfalls in Front-line Readiness 211
a robot for this reconnaissance task.27 The goal at this point would be to identify the chemical family
involved so that the level of personal protective gear for rescue operations could be set and guidelines
established for the initial medical treatment of casualties. Exact identification of the agent characteristics,
which is important for criminal prosecution, could be obtained later through laboratory analysis.28
After launching the hot zone assessment, the incident commander would seek other information to
inform his decisions. If available, the incident commander would activate mobile weather analysis and
computerized plume modeling capabilities to aid in setting the perimeters of the hot zone, the warm zone
where decontamination and initial triage would occur, and the cold zone where personnel could presumably
operate without protective gear.29 Based on such information, the incident commander would establish triage
and decontamination areas as well as the transportation corridor(s) for emergency response units.
Throughout rescue operations, he would evaluate progress and adjust plans as necessary.30
Establishing Perimeter Control of the Disaster Scene
Initially, the incident commander would set the exclusion zone conservatively and thus quite widely.
The purpose of a perimeter is to establish firm, complete control of who enters and exits the disaster area.
A first cut at this task could be quickly accomplished with crime scene tape. Refinement of the perimeter
27 A robot can be a time-saving option because people must don protective gear. One city equipped their robot with a
SAW mini-CAD that feeds data back to the command truck. Other cities have opted for the APD-2000 and a video camera.
These robots could also be used to drag victims out of a hot zone. Interviews with author: Fire Captain/Assistant Emergency
Management Coordinator (5 January 2000); Emergency Preparedness Director, Office of Emergency Services (9 February 1999);
Special Projects Program Manager, Department of Public Health (5 February 1999).
28 Interviews with author: Hazmat Coordinator/Instructor (8 September 2000); Firefighter/Hazmat Instructor/Paramedic
(28 June 2000); FBI Special Agent (19 June 2000); FBI Special Agent (16 May 2000); Emergency Preparedness Director, Office
of Emergency Services (9 February 1999); Fire Captain, Hazmat Unit (9 February 1999).
29 In addition to plume projections, some computerized modeling systems can also forecast how many people may have
been injured or killed and how many are likely to be affected by the plume, depending upon the estimated population in the
affected area at different times of the day. Some cities have weather stations atop their hazmat vehicles or at various points
around the metropolitan area. Up-to-the-minute weather data can also be obtained from a variety of other sources, ranging from
the local airport to the National Weather Service. Interviews with author: Deputy Coordinator, Fire Emergency Preparedness and
Disaster Services (3 February 2000); EMS System Analyst/Paramedic, State Department of Health and Social Services (25
January 2000); Police Detective/Bomb Squad member (19 January 2000); Project Manager, Emergency Management Planning,
Office of Emergency Management (27 July 1999); Emergency Preparedness Director, Office of Emergency Services (9 February
1999).
30 Interviews with author: Fire Captain/Assistant Emergency Management Coordinator (5 January 2000); Hazmat
Coordinator/Instructor (8 September 2000); MMRS Coordinator, Fire Department (9 May 2000); Battalion Fire Chief (19
November 1999); Battalion Fire Chief/Emergency Services Administrator (15 November 1999); Police Commander and Police
Captain, Special Operations Division (23 March 1999).
212 Ataxia: The Chemical and Biological Terrorist Threat and the US Response
zones would depend on the type of chemical involved, and better perimeter control could be achieved
gradually with additional personnel and physical barriers.31
Promptly establishing a perimeter is important to hold the number of victims to a minimum and
enable rescuers to do their jobs without undue interference. News crews monitor the emergency
communications frequencies and could quickly get to the scene, sometimes even before key response
squads.32 Continuous, live television broadcasts of the Murrah Building in Oklahoma City began twelve
minutes after the 19 April 1995 bombing.33 Some reporters would view such a disaster as a career-making
story and might be willing to do practically anything to obtain spectacular images or insider interviews for
live reports. The media's behavior could jeopardize their own health and also impede rescue operations in
the early moments critical to victims' survival. Citizens who believe that family members or friends could
be victims would also have to be kept at a safe distance, and responders would need to corral those trying
to flee the scene because exposure to toxic chemicals can cause serious health effects.34
Whether in small accidents or full-fledged disasters, police routinely establish and hold the perimeter
zone. Police are accustomed to acting independently, using basic skills to assess each situation, creating an
operational plan as they go, and calling in more personnel as needed.35 When a toxic substance is the cause
of the disaster, however, police have, with good reason, expressed doubts about their ability to fulfill
perimeter duties. A badge and a gun offer no protection under these circumstances, and most patrol officers
nationwide have little equipment or training to protect them from exposure to hazardous substances.
Depending upon their department's assets and policies, beat cops may lack even riot control masks, which
provide insufficient protection against super toxic chemicals. Therefore, some patrol officers worried about
the exposure risk should the wind shift while they were on perimeter detail. They were wary that police
31 Seattle firefighters demonstrate the crime scene tape perimeter in the instructional video "Weapons of Mass
Destruction and The First Responder." (Washington, DC: Department of Justice, Office of Justice Programs, 2000). During a
disaster, initial chaos and the impulse to rescue victims can delay setting of the perimeter. At 9:28am on 15 April 1995, just over
twenty-five minutes after the bombing of the Murrah Building, Oklahoma City police began to establish crime scene perimeters.
Outer perimeter control was secured at 11:20am. Final Report of the Alfred P. Murrah Federal Building Bombing, 3667. Some
chemical agents (e.g., mustard, soman, VX, tabun) can persist in the contaminated area for days under temperate conditions,
while others (e.g., phosgene, hydrogen cyanide) will dissipate within a few minutes. Frederick Sidell, Ernest Takafuji, David
Franz, eds., Medical Aspects of Chemical and Biological Warfare: Warfare, Weaponry and the Casualty (Washington, DC: US
Army, Office of the Surgeon General, 1997), 13942, 198200. Also, interviews with author: Fire Chief (15 May 2000);
Battalion Fire Chief (15 November 1999); Deputy Director, Office of Emergency Management (27 July 1999).
32 For instance, one city's SWAT and bomb units responded to a 911 call reporting a possible school shooting incident
to find eight television news cameras already at the school. Interview with author: Police Detective/Bomb Squad member (19
January 2000).
33 Final Report of the Alfred P. Murrah Federal Building Bombing, 366.
34 Interviews with author: Police Lieutenant, Tactical Support Office (18 September 2000); District Fire Chief, EMS
Division (2 March 2000); Battalion Fire Chief (15 November 1999).
35 Interview with author: Police Detective/Bomb Squad member (19 January 2000).
Chapter 6 Metropolis, USA: Progress, Pitfalls in Front-line Readiness 213
supervisors confronting this novel situation could bobble instructions to line officers. Also, some officers
predicted that off-duty police beeped to report as reinforcements might ignore the page if they knew poison
gas had been released.36
Some perimeter strategies have been devised to take regular patrol officers out of harm's way.
Instead of police, some cities plan to assign hazmat and fire crews to establish scene control initially.37
Other cities have found a viable way for police to assume their normal perimeter control duties in these
circumstances without incurring the expense of training and equipping patrol officers for level A
operations. This approach is described in box 6.1. If special police units were deployed on the warm
zone perimeter, regular officers could be stationed at the cold zone perimeter positions-those upwind
and crosswind of the hot zone-where they would be unlikely to encounter concentrations of toxic material
Box 6.1: Assigning Special Police Units the Perimeter Control Mission
Instead of relying on regular uniformed officers, SWAT and special operations police can be
posted on the perimeter in the event of a terrorist attack using chemical agents. These special units
are accustomed to taxing missions, so some cities have trained and equipped them with level B
protective gear to hold the warm zone perimeter.1 In a variant of this approach, another police
department has prepared a trio of officers and a sergeant in each of its districts to report to the scene
immediately, appropriately equipped and trained to operate in the warm zone. This concept spreads
the requisite resources throughout the city to enable a quick, if modest, response. Special operations
police, also level B trained, will augment the early deployment teams to flesh out perimeter control
capabilities.2
NOTES
1. Interviews with author: Deputy Director, Office of Emergency Management (26 May 2000); Deputy Coordinator, Fire
Emergency Preparedness and Disaster Services (3 February 2000); Police Captain/Firing Range Director (5 February 1999).
In an adaptation of this approach, one city is recruiting 130 volunteers from its patrol officers to serve as a standing unit for
perimeter duty in level B protective gear. Interviews with author: Police Detective/Bomb Squad member (19 January 2000).
Another city is also thinking about outfitting and training its transportation police to level B so that they can assist with the
perimeter. Interview with author: Deputy Coordinator, Fire Emergency Preparedness and Disaster Services (3 February
2000).
2. Interviews with author: Police Commander and Police Captain, Special Operations Division (23 March 1999).
36 This attitude and aptitude may change in cities that train their police force well and procure protective gear for
officers. Not all departments distribute riot control masks for patrol units. Even in departments that do, officers interviewed said
that several years often pass in which beat cops do not use these masks. Interviews with author: Battalion Fire Chief, Special
Operations (25 May 2000); Director, Emergency Services Department (18 May 2000); EMS System Analyst/Paramedic, State
Department of Health and Social Services (25 January 2000); Police Detective/Bomb Squad member (19 January 2000);
Emergency Preparedness Director, Office of Emergency Services (9 February 1999); Police Lieutenant and Police Captain,
Special Operations Division (8 February 1999); Police Captain/Firing Range Director (5 February 1999).
37 Interviews with author: Fire Chief (15 May 2000); Battalion Fire Chief (15 November 1999); Deputy Director,
Office of Emergency Management (27 July 1999).
214 Ataxia: The Chemical and Biological Terrorist Threat and the US Response
sufficient to cause injury.38
Some police departments have begun to issue patrol officers a reasonable amount of respiratory
protection so that they would be able to go about various cold zone duties with confidence. For example,
the incident commander might ask police to escort special equipment trailers to the area and to bust open
transportation corridors so that rescue vehicles could get to and from the disaster scene.39 Regular patrol
officers are a challenge to equip because they are notoriously tough on their gear, and police departments
are reluctant to train line personnel to use complicated respirators when so many other certifications must
be met.40 Therefore, whatever gear a department chooses needs to be robust, low maintenance, very easy to
use, and suited to the task to be performed. If patrol officers are to be stationed considerable distances away
from the hot zone, then the officers could be outfitted with a high-performance riot control agent mask that
has canisters to filter extremely toxic industrial and even warfare chemicals (e.g., the MSA Millenium
Chemical-Biological and Advantage 1000 masks). This gear choice is multipurpose, but cities were also
weighing other options.41 To provide additional manpower, one city had arranged for area "mini-cops,"
namely the transit police and those who guard empty buildings, to hold the perimeter once the disaster scene
38 Interviews with author: Project Manager, Emergency Management Planning, Office of Emergency Management (27
July 1999); Police Lieutenant (23 March 1999); Emergency Preparedness Director, Office of Emergency Services (9 February
1999); Police Lieutenant and Police Captain, Special Operations Division (8 February 1999); Police Captain/Firing Range
Director (5 February 1999).
39 Note that getting equipment trailers to the scene in a timely fashion is such a concern in one city that their equipment
trailer has been palletized and sling-wrapped. Special arrangements have been made for it to be brought in by helicopter.
Interview with author: Paramedic (12 May 2000). On this police role, comments were also made by: Medical
Toxicologist/Poison Control Center Director (13 June 2000); District Fire Chief, EMS Division, (2 March 2000); Police
Detective/Bomb Squad member (19 January 2000); Project Manager, Emergency Management Planning, Office of Emergency
Management (27 July 1999).
40 Interviewees observed that police habitually toss seldom-used items in the trunks of their patrol cars where they
bounce around, ignored, until the moment they are needed. Interviews with author: Detective/Bomb Squad (19 January 2000);
Fire Captain/Assistant Emergency Management Coordinator (5 January 2000); Police Lieutenant (8 February 1999); Police
Captain, Special Operations Division (8 February 1999). See also the discussion of the new certification point in chapter 5.
41 The Millennium Chemical-Biological Mask is designed for extended periods of wear, equipped with a speaking
diaphragm and drinking tube. In addition to being effective against biological agents, the mask has been tested both by the
manufacturer and independent laboratories, is certified by the National Institute on Occupational Safety and Health for protection
against chloroacetophenone, chlorobenzylidene, P-100 particulate efficiency level and particulates, and meets the chemical
weapon agent protection requirements of the Chemical Agent Safety and Health Policy Action Committee. The canister contains
a high-efficiency particulate air filter and a carbon bed to absorb gases and liquid vapors. The military version of the mask is the
MCU-2/P. The manufacturer's list price for a single mask kit is $297, and the cost to those meeting federal Government Services
Administration qualifications is $167.50. The Advantage® is a less expensive version of the Millennium mask. "Advantage®
1000 CBA-RCA and Millennium Gas Masks," MSA Data Sheet 05-00-03 (Pittsburgh, Pa.: MSA, August 1999). Whereas self-
contained breathing apparatus is imperative for those working inside or in close proximity to the warm zone, some cities are
considering escape-only masks or positive pressure hoods, options that do not require fit tests or annual certification. This type
of gear may be appropriate in situations when the respiratory threat is minimal. Air purifying respirators, which do require a fit
test, are another equipment choice. Some police departments are also putting a couple of Tyvek suits in the trunks of patrol cars.
Interviews with author: Police Lieutenant, Tactical Support Office (18 September 2000); Hazmat Coordinator/Instructor (8
September 2000); Hazmat Trainer/Firefighter/Paramedic (2 August 2000); Paramedic (12 May 2000); Sergeant, Fire Department
(9 May 2000); Fire Captain/Assistant Emergency Management Coordinator (5 January 2000).
Chapter 6 Metropolis, USA: Progress, Pitfalls in Front-line Readiness 215
had been mostly cleared.42 Physical barriers, such as sawhorses or chained-link fencing, could also reinforce
the perimeter.43
One of the dilemmas that police anticipate after a chemical terrorist attack is sheer, utter panic, with
some attempting to bolt the scene and others to aid the wounded. Police officers expressed uncertainty about
the appropriate level of force to be used to hold the perimeter. Although anyone in regular clothes who
entered the contaminated zone could be harmed, police presumed that they would not be authorized to use
physical force. Rather, police guessed they would be told to use verbal orders and psychological persuasion
to try to maintain order. Perhaps, they would be asked to help fire crews hose people down both to
decontaminate them and to discourage them from leaving the area.44 In some jurisdictions, law enforcement
officers have standing authority to use non-lethal force to maintain order during riots or other difficult
circumstances.45 Elsewhere, police departments had yet to clarify use of force policies for exigent situations
involving large numbers of terrified, confused, and desperate people.
Other Law Enforcement Missions
In addition to perimeter control, police would be asked to attend to the security of the rescuers.
SWAT teams would be on the lookout for snipers and other signs that terrorists might still be at the scene.
Given the need for SWAT teams to have tactical and tactile agility to operate in a potentially hostile
environment, cities were making different decisions about what level of personal protective clothing these
42 Deploying mini-cops, who have a certain amount of academy training and are licensed by their local law enforcement
authority, can free up police officers to answer regular 911 calls. Interviews with author: Police Commander and Police Captain,
Special Operations Division (23 March 1999).
43 Just over three hours after the Oklahoma City bombing on 19 April 1995, chained-link fencing was brought to the
scene for more effective perimeter control. By 4:30 on the afternoon of the bombing, personnel from the Oklahoma City Police,
County Sheriff's Office, and Departments of Military Personnel and Public Safety had met to establish around-the-clock staffing
rotations for an eighteen-square-block area around the Murrah building. After Action Report: Alfred P. Murrah Federal Building
Bombing (Oklahoma City, Okla.: Oklahoma Department of Civil Emergency Management, n.d.), 15.
44 For instance, those trying to depart might be told where they should gather to be decontaminated, receive medical
assistance, and be reunited with their companions. Giving people the information they want can have a calming effect,
convincing people that they will get the help they desire by remaining at the scene. Also, should police and fire crews promptly
begin to hose down the victims, the water pressure should be low and caution exercised if the temperature is cold. Interviews
with author: Director, Emergency Management Division, County Department of Public Safety (19 September 2000); Police
Lieutenant, Tactical Support Office (18 September 2000); Hazmat Coordinator/Instructor (8 September 2000); District Fire
Chief, EMS Division (2 March 2000); Police Detective/Bomb Squad member (19 January 2000); Fire Captain/Assistant
Emergency Management Coordinator (5 January 2000); Project Manager, Emergency Management Planning, Office of
Emergency Management (27 July 1999); Police Captain/Firing Range Director (5 February 1999).
45 During one city's chemical functional exercise, local police officers shocked some by firing non-lethal weapons at
those trying to breach their perimeter. Interview with author: Fire Captain/Assistant Emergency Management Coordinator (5
January 2000).
216 Ataxia: The Chemical and Biological Terrorist Threat and the US Response
teams would wear in a contaminated setting.46 The incident commander would also probably order the bomb
squad to search for other toxic or explosive boobytraps.47 Terrorists have been known to plant additional
bombs to injure the initial responders and cause further havoc.48 Such tactics can have a demoralizing effect
on the rescuers and reduce the public's confidence in the government's ability to handle such situations if
additional people are injured. Until SWAT and bomb squads declare the scene free of such hazards, the
incident commander would try to minimize the number of rescuers involved.
Dealing with the second device issue under the pressure of a disaster rescue is easier said than done.
During one city's full chemical drill, the responders got so caught up in the rescue that they forgot to look
for the dummy secondary device.49 In the second hour of the rescue at the Murrah Building in Oklahoma
City, at least two bomb scares forced rescuers to retreat, the incident command post to be relocated, and
rescue operations to be suspended until the "all clear" was given.50 To enable faster, more effective searches,
bomb squads and hazmat teams in several cities have begun cross-training, and some have begun routinely
deploying together on calls to improve operational efficiency.51
Next, police would also be mindful that while lifesaving efforts take precedence over criminal
investigation, preservation of evidence is of key importance. Particularly once decontamination of victims
begins, key pieces of evidence could be compromised or lost entirely. Depending upon local capabilities,
the incident commander might instruct the bomb squad or another unit trained in toxic evidence collection
46 One city is putting its SWAT team in level A after tests that showed that they could still hit targets in a slightly larger
area than they would in their regular gear. Interview with author: Paramedic (12 May 2000). In 1997, another police department
put its SWAT team in level As and found that they were unable to fire their guns with sufficient precision. Therefore, they
concluded that their SWAT team would use level Bs and SCBA. Interview with author: Lieutenant/Hazmat Commander (10
March 1999). Also on level Bs for SWAT teams: Police Lieutenant, Tactical Support Office (18 September 2000); Hazmat
Instructor/Firefighter/Paramedic (2 August 2000); Deputy Director, Office of Emergency Management (26 May 2000); Project
Manager, Emergency Management Planning, Office of Emergency Management (27 July 1999).
47 Interviews with author: Police Lieutenant, Tactical Support Office (18 September 2000); Hazmat
Coordinator/Instructor (8 September 2000); Deputy Director, Office of Emergency Management (26 May 2000); Battalion Fire
Chief, Special Operations (25 May 2000); Paramedic (12 May 2000); District Fire Chief, EMS Division (2 March 2000); Deputy
Coordinator, Fire Emergency Preparedness and Disaster Services (3 February 2000); Battalion Fire Chief (15 November 1999);
Physician/EMS Medical Director (13 November 1999).
48 Alan Sverdlik, "Blasts Rock Atlanta Abortion Clinic; At Least 7 People Slightly Injured in Explosions 45 Minutes
Apart," Washington Post, 17 January 1997.
49 Interview with author: General Manager, Emergency Department (22 September 2000); Physician, Hospital
Emergency Department (11 May 1999).
50 While bomb squads combed the site, rescue efforts were suspended from 10:28am to 11:22am. After Action Report:
Alfred P. Murrah Federal Building Bombing, 2, 14; Final Report of the Alfred P. Murrah Federal Building Bombing, 3678.
51 Interviews with author: Police Lieutenant, Tactical Support Office (18 September 2000); Paramedic (12 May 2000);
Battalion Fire Chief (15 November 1999); Chief of Response Division, State Department of Civil Emergency Management (13
April 1999); Police Lieutenant (23 March 1999); Police Commander and Police Captain, Special Operations Division (23 March
1999); Paramedic/Emergency Planner, Public Health Department (4 February 1999).
Chapter 6 Metropolis, USA: Progress, Pitfalls in Front-line Readiness 217
to protect or gather evidence using equipment especially designed for toxic crime scenes.52 The skills of
toxic evidence collection are unfamiliar to many metropolitan police departments. Successful prosecution
of the perpetrators would depend upon proper collection and analysis of samples and other evidence, as well
as strict observance of chain-of-custody rules for that material. Police would also want to get contact
information for victims and witnesses to facilitate interviews. As soon as is practicable, the incident
commander would notify the nearest Federal Bureau of Investigation (FBI) office of the circumstances. The
FBI would dispatch evidence collection personnel who can operate in a hot zone.53 At the conclusion of
rescue operations, site command would transition to law enforcement authorities.
A final chore that would draw upon police resources relates to whether the situation merited the
sheltering-in-place or rapid evacuation of some citizens. If a significant toxic cloud were present, police
would be directed to ask people in the immediate downwind area to remain indoors until the hazard had
passed or dissipated.54 Further downwind from the disaster scene, citizens might be evacuated. Most cities
and all states have evacuation plans, but their gaping defects have surfaced when these plans were activated.
For example, when Hurricane Floyd struck the southern coastal states in mid-September 1999, governors in
Florida, Georgia, and South Carolina ordered the evacuation of coastal regions. Routes inland turned into
parking lots, and for some the traffic jams lasted up to seventeen hours.55 Experience has shown that just
52 Isolating and collecting contaminated evidence requires special procedures and equipment that not all local police
departments have. SWAT and explosive ordnance disposal (EOD) teams are being trained in some cities to undertake this task.
Interview with author: Director, County Emergency Management (21 September 2000); Police Lieutenant, Tactical Support
Office (18 September 2000); FBI official (1 August 2000); Battalion Fire Chief/Special Operations Officer (25 May 2000); FBI
Special Agent (16 May 2000). Barrier Products, LLC began fabricating special contaminated evidence kits after the collective
suicides of Heaven's Gate cult members in March 1997. The kits, called Portable BioSeal Facility Systems, include a roll of
polyaluminum foil-Tyvek laminate wrapping material, that when welded shut with a heated unit forms a sealed containment
package around contaminated items, fully isolating any associated hazardous gases or liquids. For further information, see the
Barrier Products website at: http://www.bioseal.com.
53 As chapter 4 describes, the FBI's Hazardous Materials Research Unit is trained and equipped specifically for this
task. Some FBI field offices are also acquiring the capability to perform evidence collection in a contaminated area. FBI
personnel in one city trained local firefighters to collect evidence in a contaminated zone. Interview with author: Battalion Fire
Chief, Special Operations (25 May 2000).
54 Sheltering-in-place involves shutting off air handling systems, closing all windows and doors, and tuning to local
emergency or news outlets for official notifications of when it is safe to go outside. Hawley, Hazardous Materials Response &
Operations, 1302. Coordinator/Instructor (8 September 2000).
55 Hurricane Floyd was by no means the only time that citizens have cursed the evacuation more heartily than the
original misfortune. The evacuation orders put some two million Floridians, 500,000 Georgians, and 800,000 South Carolinians
on the road at roughly the same time. Authorities eventually recognized that they could relieve some of the congestion by
turning two-way highways into one-way highways headed inland. Bruce Henderson, Scott Dodd, and David Perlmutt, "Millions
on Run From Fierce Floyd," Charlotte Observer, 15 September 1999; Schuyler Kropf, "Evacuation Traffic Jam Sparks Anger in
S. Carolina," Reuters, 15 September 1999; Alan Judd, "Highways Clogged, Hotel Rooms Scarce," Atlanta Journal- Constitution,
15 September 1999; Lynne Langley, Arlie Porter, and Robert Behre, "Lowcountry Lies in Path of Hurricane," Charleston Post
and Courier, 15 September 1999.
218 Ataxia: The Chemical and Biological Terrorist Threat and the US Response
having a plan on paper is a far cry from having an effective evacuation plan.56 By all indications, police
would have difficulty organizing and implementing a large-area evacuation on short notice.
Rescue Operations
The crux of a disaster scene is rescue operations. The incident commander's natural choice for hot
zone rescuers would be a city's hazmat squad, but, as needed, some cities reported plans to insert SWAT and
EMS personnel to help extricate victims.57 Should the hazard assessment mandate level A suits, rescuers
noted that putting on this gear consumes time. A widely held misperception about a regulatory requirement
for a pre-insertion medical check-up exacerbated rescuers' worries about this time lag. This
misunderstanding was so pervasive that even very experienced firefighters made impassioned pleas that it
be waived if lives were at stake.58 To set the record straight, Occupational Safety and Health Administration
(OSHA) regulations do not stipulate pre-entry health monitoring (e.g., blood pressure), but they do specify
medical check-ups at other times and good safety practice would always incorporate an exam as personnel
exit the hot zone.59 For those still concerned about running afoul of OSHA regulations, box 6.2 describes
a pragmatic time-saver to speed rescues in level A gear.
Given the urgency of administering antidotes to victims exposed to poison gas, several experienced
rescuers strongly advocated the use of snatch-and-grab tactics to extricate victims with the utmost haste.60
56 Interview with author: Police Lieutenant, Tactical Support Office (18 September 2000); Police Lieutenant (23 March
1999).
57 Some cities are sending hazmat squads only into the hot zone. Interviews with author: Director, Emergency Services
Department (18 May 2000); Fire Chief (15 May 2000); Emergency Management Specialist, Office of Emergency Management (9
May 2000). Other cities will also send in EMS personnel to help with the rescue. Interviews with author: Police Lieutenant,
Tactical Support Office (18 September 2000); Police Detective/Bomb Squad member (19 January 2000); Physician/EMS
Medical Director (13 November 1999). On deploying SWAT team members for hot zone rescue: Paramedic (12 May 2000);
Project Manager, Emergency Management Planning, Office of Emergency Management (27 July 1999).
58 With regard to foregoing the level A medical exam, they argued, no one expects police on patrol to stop and put on
eye protection and ear plugs before they fire their gun, even though they are required to do so at the firing range. Interviews with
author: Chief, County Fire Department (9 September 1999); Battalion Fire Chief (9 February 1999); Fire Captain, Hazmat Unit
(9 February 1999).
59 OSHA Regulation 1910.134 specifies that hazmat personnel receive an annual physical, or, at the discretion of the
physician, a biannual checkup. In addition, regulations also require that EMS personnel be standing by for medical assistance
during a hot zone entry. Checkups are required in the event of a chemical exposure injury or an exposure to a chemical above the
permissible exposure limit. Hawley, Hazardous Materials Response & Operations, 10.
60 Interviews with author: Battalion Fire Chief (9 February 1999); Fire Captain, Hazmat Unit (9 February 1999). One
county has put four high-level protection suits on each fire truck so that front-line personnel can perform snatch-and-grab.
Interview with author: Chief, County Fire Department (9 September 1999).
Chapter 6 Metropolis, USA: Progress, Pitfalls in Front-line Readiness 219
Box 6.2: Cutting Down on Dress-out Time for Level A Gear
One city's fire department has instituted a policy that can measurably reduce the level A
dress-out time, requiring hazmat personnel to undergo baseline medical checks at the beginning of
every shift. Bypassing blood pressure and other vital sign checks at the scene can cut the suit up time
in half. This city's hazmat squad also conducts daily checks of its specialized detectors, which helps
personnel with equipment familiarization. The hazmat squad is also responsible for routinely
checking the gear on the city's MMRS equipment trailer.1
NOTES
1. Harkening again to the widespread misinterpretation of the regulations on this matter, the veteran firefighter who described
this policy expressed concern that foregoing the field medical exam could lead to an OSHA violation, but that penalty was
deemed acceptable if lives could be saved. Interview with author: Battalion Fire Chief (15 November 1999). Chris Hawley,
Hazardous Materials Response & Operations (Albany, NY: Delmar, Thomson Learning, 2000), 11.
As one battalion chief put it, "If there is a lot to be gained, we'll risk a lot."61 Should the reconnaissance data
reveal a less severe hazard, the incident commander could insert firefighters in SCBA and taped-down bunker
gear into the hot zone to rescue known live victims.62 The risk to snatch-and-grab rescuers could be further
reduced by aiming water hoses with fog nozzles to clear away the ambient hazard. Dousing the rescuers and
victims as they exit the hot zone would also jumpstart decontamination of the victims.63 If the attack
occurred indoors, the vapor hazard could be significantly decreased for victims and rescuers alike by
positioning fans in doorways.64
Decontamination Operations
Decontamination of people exposed to hazardous substances is a multi-step process.65 The layman's
impression is that decontamination significantly affects the survival of victims, but in truth its main purpose
is to protect the health and safety of on-scene rescuers and hospital personnel who are not typically in
61 Interview with author: Battalion Fire Chief, Special Operations (25 May 2000).
62 If nerve agent vapor is present, rescuers in standard turnout gear with SCBA can enter a contaminated building or the
downwind area of a hot zone for thirty minutes. See also, footnote 24. 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 (Aberdeen, Md.: US Army Soldier and Biological Chemical Command, August 1999), 1017.
63 Interviews with author: Deputy Director, Office of Emergency Management (26 May 2000); Fire Captain, Hazmat
Unit (9 February 1999).
64 For example, the concentration of an agent indoors can be reduced by fifty to seventy percent within ten minutes.
Specific instructions on the positioning and size of fans, as well as when to use positive or negative pressure fans, are provided in
The Use of Positive Pressure Ventilation (PPV) Fans to Reduce the Hazards of Entering Chemically Contaminated Buildings:
Summary Report (Aberdeen, Md.: US Army Soldier and Biological Chemical Command, October 1999).
65 The four types of decontamination are emergency, gross, formal, and fine. For a tutorial on the distinctions and how-
to's, see Hawley, Hazardous Materials Response & Operations, 14657.
220 Ataxia: The Chemical and Biological Terrorist Threat and the US Response
protective gear.66 Cities began adopting tactics to get the job done with all possible speed using front-line
fire equipment, and their commonsense approach passed Defense Department-sponsored tests in 1999.
Overturning conventional wisdom about the need for bleach or soap decontamination solutions, studies show
that it would probably be most expedient and effective to use water alone. Taking time to dilute a bleach
solution properly or to add soap could delay the onset of decontamination and cause additional medical
problems.67 The overriding factor in decontamination is to begin as soon as possible.
Weather conditions permitting, firefighters would probably start gross decontamination of the
victims using fog nozzles as soon as hoses were hooked to hydrants. Ladder trucks could raise boom nozzles
to create large area, high-volume, low-pressure outdoor showers or engines could be arranged side-by-side
to set up decontamination corridors. Firefighters would adjust configurations of front-line equipment
according to the number of victims. Well-drilled crews could set up an impromptu decontamination corridor
in fifteen minutes or less. Although the requirements vary depending on the agent used, the initial goal
would be to get victims to shower thoroughly for at least two to three minutes.68 Ideally, victims would be
separated into different holding areas, prioritizing those with more serious exposure symptoms for
decontamination first.69 Firefighters-often dual-trained as emergency medical technicians (EMTs)-could
66 According to a physician who has treated hundreds of chemical agent casualties, not a single one of whom was
decontaminated, the most dangerous exposure risk-vapor-evaporates as the victim moves to the medical treatment area. "By
the time the casualty hits a medical response station, you are not going to do the casualty one bit of good by decontaminating the
casualty's skin. After thirty minutes, that agent is in the skin; mustard is in the skin. The nerve agent has either killed the
casualty, or else there has not been enough on the skin to do any harm." Dr. Fred Sidell, "Chemical Agents: Overview," in
Proceedings of the Seminar of Responding to the Consequences of Chemical and Biological Terrorism, Office of Emergency
Preparedness (Washington, DC: US Department of Health and Human Services, Public Health Service, 11-14 July 1995), page
1-73. See also, page 1-71.
67 Use of bleach solutions is also not advisable for victims with abdominal, thoracic, or neural wounds. Care must also
be taken to avoid areas near the victims' eyes and mucous membranes. Employment of soapy solutions if a blister agent has been
released could also increase the damage such agents can cause. Guidelines for Mass Casualty Decontamination, 56. To mix a
decontamination solution quickly, one city has decided have its firemen dump a product called Pool Shock-stackable,
unbreakable packages of chlorine-into its pumper trucks en route to the incident scene. This simple approach, in the words of
those who described it, obviates the need for measurement and therefore is "fireman proof." Another fast approach that avoids
measurement is to buy bleach in quarts rather than in bulk. Interviews with author: Police Lieutenant (23 March 1999);
Emergency Preparedness Director, Office of Emergency Services (9 February 1999); Battalion Fire Chief (8 February 1999).
68 Interviews with author: Fire EMS Statistician (30 August 2000); Deputy Director, Office of Emergency Management
(26 May 2000); Battalion Fire Chief, Special Operations (25 May 2000); Director, Emergency Services Department (18 May
2000); Fire Chief (15 May 2000); Paramedic (12 May 2000); MMRS Coordinator, Fire Department (9 May 2000); Emergency
Management Specialist, Office of Emergency Management (9 May 2000); District Fire Chief, EMS Division (2 March 2000);
Battalion Fire Chief, (19 January 2000); Fire Captain/Assistant Emergency Management Coordinator (5 January 2000).
Instructions for positioning trucks and ladders for decontamination can be found in Guidelines for Mass Casualty
Decontamination, 713; Hawley, Hazardous Materials Response & Operations, 14855.
69 At first, victims can be separated into ambulatory and non-ambulatory categories. Those who have liquid agent on
their skin or clothing, were closest to the source of the agent, reported exposure to vapor or aerosol, or have serious clinical
symptoms would receive first priority for decontamination. Next, ambulatory cases could be further separated into those
moderately showing the characteristic signs of exposure, who would be the second in priority for decontamination. Also in this
category would be individuals who suffered other conventional injuries. Finally, those who were farthest away from the source
of the agent and have no outward exposure symptoms could wait until last for decontamination. This final group should be
Chapter 6 Metropolis, USA: Progress, Pitfalls in Front-line Readiness 221
perform initial triage by observing the victims and trying to distinguish between individuals who were more
frightened by the situation than in genuine need of decontamination.
Optimally, rescuers would begin the decontamination process by instructing victims to disrobe. Even
those in physical distress might object to taking off their clothes in public, so rescuers would have to explain
clearly that taking off one's outer clothing can remove roughly 80 percent of the contamination hazard.70
Separate showers for men and women would help preserve victims' privacy. Failure to erect barriers that
shield victims from prying eyes can result in harsh criticism from the media, the public, and even those
rescued.71
Plans often call for impromptu front-line fire truck and engine set-ups to be augmented with a
second, formal stage of more careful showering and scrubbing of residual contaminants from the victims,
using bleach or soap solutions, as appropriate. Some cities have trailers filled with commercially available
field decontamination systems and so-called tent cities.72 Other cities may bring in a dedicated
decontamination truck or bus, which is a more expensive option that some first responders view with
cynicism.73 To cut set-up time down to about eight minutes, one rescue team pre-packed its tents, using
periodically checked for the onset of clinical symptoms that might indicate they should receive a higher decontamination priority.
Guidelines for Mass Casualty Decontamination, 145.
70 Undressing also reduces the chances that showering could transfer the agent from the clothing to the skin. Clothing
should be taken off from head to toe. If use of a biological agent is suspected, victims should be doused before they remove their
clothing. Guidelines for Mass Casualty Decontamination, 6.
71 On 24 April 1997, the nationwide print and electronic media splashed images of the Washington, DC fire
department's efforts to decontaminate individuals that they thought had been exposed to anthrax. As it turned out, the container
placed in front of the B'nai B'rith headquarters in the capital city was part of a hoax. The only things exposed were the victims,
thirty whom were stripped to their undergarments for decontamination within full view of media cameras. A further 109 people
from this building were quarantined, and two blocks of the city were cordoned off from traffic. The city's emergency response
community, which had previously been described as a model of preparedness, was harshly criticized afterwards. For a dissection
of this response, see Jessica Stern, Fire Department Response to Biological Threat at B'nai B'rith Headquarters, US Fire
Administration Technical Report Series, report 114 (Washington, DC: Federal Emergency Management Agency, 1997). See
also, Michael Powell and Allan Lengel, "Chemical Alert Traps Workers in Buildings," Washington Post, 25 April 1997; Sari
Horwitz, " FBI Sends Alert to Jewish Groups," Washington Post, 26 April 1997; "Defense Department Establishes DC Anti-
terrorism Unit," Armed Forces Newswire, 13 January 1997.
72 The contents of these trailers vary from city to city, depending upon prevailing weather conditions, resources, and the
city's decontamination plan. They may contain tents, hoses, decontamination solutions, scrub brushes, personal protective gear,
backpack tanks and decontamination sprayers, plastic storage bags, pools to catch contaminated water, heaters and propane tanks
to heat the water, towels, and temporary or disposable clothing for the victims. Interviews with author: Paramedic (12 May
2000); Emergency Management Specialist, Office of Emergency Management (9 May 2000); MMRS Coordinator, Fire
Department (9 May 2000); District Fire Chief, EMS Division (2 March 2000); Deputy Director, Office of Emergency
Management (27 July 1999); Emergency Preparedness Director, Office of Emergency Services (9 February 1999).
73 One city spent $80,000 to install shower heads and other features (e.g., hydraulic lift for wheelchair patients) on a
delivery truck. This truck can decontaminate over twenty people at a time, with tents stored aboard to expand its capacity. Funds
for this vehicle came from a state law requiring private facilities to pay for hazmat services. The truck is to be deployed to all
hazmat incidents. Interview with author: Fire Chief (15 May 2000). Other locations have also invested in mass decontamination
trucks. Interview with author: Chief, County Fire Department (9 September 1999). More than one individual expressed the view
222 Ataxia: The Chemical and Biological Terrorist Threat and the US Response
velcro to secure pools and hoses at the appropriate places inside the tents, which inflate with the push of an
air button.74 Some cities were also hoping to save time by stationing their decontamination trailer(s) with
their hazmat team(s); others situated these trailers at strategic area locations.75 As they exit the
decontamination process, victims would be given Tyvek suits, spare clothing, or even garbage bags to wear.76
Depending on the size of a tent city and rescuers' training, dozens of people could be herded through
decontamination lines simultaneously.77
Decontamination operations, which are labor intensive and exhaustive, would soon deplete a city's
supply of trained responders. Hours would be required to decontaminate hundreds of people. To provide
a ready supply of reinforcements, fire departments have designated engine companies to serve as hazmat and
decontamination squads, equipping and training them to level A and level B operations, respectively.78 Some
cities were also spreading training and equipment to neighboring municipal areas, so that their mutual aid
partners could help. In one metropolitan area, each jurisdiction was asked to offer one fire house to serve
as a decontamination squad on all shifts. Between $1,300 and $1,500 worth of equipment can outfit a fire
that these fancy decontamination rigs will soon be seen as dinosaurs because the front-line fire engine set-up is much more
expedient and tent cities much less expensive. Moreover, these trucks may be unable to make it to the scene in time to be of
much use. Interviews with author: Hazmat Instructor/Firefighter/Paramedic (2 August 2000); Paramedic (12 May 2000);
Physician, Hospital Department of Emergency Medicine (24 March 1999).
74 All that remains is to hook the water hoses to outside lines. Interview with author: Hazmat Specialist/Instructor (9
February 1999).
75 Interviews with the author: Deputy Director, Office of Emergency Management (27 July 1999); Emergency
Preparedness Director, Office of Emergency Services (9 February 1999).
76 Interview with author: Battalion Fire Chief (8 February 1999). Industrial trash bags come two thousand per roll and
could provide slight modesty and thermal protection for victims. Interview with author: Police Lieutenant (23 March 1999).
Another rescuer thought that asking the victims to wear garbage bags-a cheap and easy option-would rob them of their dignity
and also show that city emergency personnel were less than well prepared to handle the situation. Interview with author: Fire
Captain, EMS Division (27 July 1999).
77 Victims can be moved quickly through decontamination lines if the attending personnel are well trained. For
example, the 100-person National Medical Response Team in Winston-Salem, North Carolina, practices regularly and can
decontaminate twenty non-ambulatory and two hundred ambulatory people per hour. Interview with author: Physician/National
Medical Response Team member (11 May 1999). In one city's decontamination drill, however, it took three hours to process
twenty people with an indoor shower. Interview with author: Deputy Fire Chief (23 March 1999). Other cities concerned about
how long it would take them to set up decontamination lines gave some thought to busing victims to car washes and water
amusement parks, but discarded the idea. Interviews with author: Emergency Management Specialist, Office of Emergency
Management (9 May 2000); Registered Nurse/Emergency Planner, Public Health Department (7 April 2000).
78 Interviews with author: Hazmat Coordinator/Instructor (8 September 2000); Fire EMS Statistician (30 August 2000);
Deputy Director, Office of Emergency Management (26 May 2000); Battalion Fire Chief/Special Operations Officer (25 May
2000); Director, Emergency Services Department (18 May 2000); EMS Specialist/Paramedic (12 May 2000); MMRS
Coordinator, Fire Department (9 May 2000); Deputy Coordinator, Fire Emergency Preparedness and Disaster Services (3
February 2000); Fire Captain/Assistant Emergency Management Coordinator (5 January 2000); Battalion Fire Chief (17
November 1999); Battalion Fire Chief (15 November 1999); Fire Captain, EMS Division (27 July 1999); Lieutenant/Hazmat
Commander (10 March 1999); Fire Lieutenant and Fire Captain (5 February 1999).
Chapter 6 Metropolis, USA: Progress, Pitfalls in Front-line Readiness 223
house to function in a backup decontamination capacity.79 The incident commander would probably request
such assets via the emergency operations center described in box 6.3. Another pool of local backups possibly
available to an incident commander would be the hazmat teams from private industry sites.80 Unless the
attack was of truly astronomical proportions, local rescuers do not anticipate calling upon rescuers from
outside the region because they could not arrive within sufficient time and some of the federal teams would,
quite frankly, be more trouble than they were worth. Local concerns about being bombarded by outside aid
teams are discussed in box 6.4.
Triage and Initial Medical Treatment
The goal of triage and on-scene medical care is to stabilize patients before transport so that definitive
treatment can be given in a more controlled hospital setting. During triage, EMS crews, aided in these
circumstances by hazmat crews and firefighters, would quickly evaluate the condition of patients and
prioritize those with the most severe injuries as the first to receive attention. Color-coded tags would indicate
a person's condition and treatment priority.81
79 Inexpensive versions of much of the requisite equipment can readily be found at hardware stores. Interviews with
author: Director, County Emergency Management (21 September 2000); Hazmat Instructor/Firefighter/Paramedic (2 August
2000); Battalion Fire Chief, Special Operations (25 May 2000); Deputy Coordinator, Fire Emergency Preparedness and Disaster
Services (3 February 2000); Deputy Director, Office of Emergency Management (27 July 1999); Fire Chief (13 April 1999);
Assistant Director, Office of Emergency Management (23 March 1999); Police Lieutenant (23 March 1999); Deputy Fire Chief
(23 March 1999); Emergency Planner (8 March 1999); Fire Lieutenant and Fire Captain (5 February 1999).
80 Interviews with author: Director, Emergency Management Division, County Department of Public Safety (19
September 2000); Battalion Fire Chief, Special Operations (25 May 2000); EMS Licensing Agent, State Department of Public
Safety (27 January 2000); EMS System Analyst/Paramedic, State Department of Health and Social Services (25 January 2000);
Deputy Fire Chief (23 March 1999).
81 EMS crews employ a number of triage systems, such as Simple Triage and Rapid Treatment/Transport, to prioritize
patients. One city plans to affix a numbered, waterproof Tyvek wrist band to victims in order to indicate level of problem. The
same number would identify bags that contain victims' clothing and personal items. Interview with author: Fire Chief (14 June
1999).
224 Ataxia: The Chemical and Biological Terrorist Threat and the US Response
Box 6.3: Emergency Operations Center Coordination of Local, Regional Assets
Once it is understood that an event of significant proportions has taken place, designated
officials from all of the responding agencies would be paged to a city's emergency operations center
to help coordinate the disaster response. This center-the civilian equivalent of a war room-would
be open around the clock until normalcy was restored. Aside from public safety and health
agencies, the public works department, which can supply a great deal of logistical assistance to the
incident commander, and public utility companies (e.g., electric, gas, telephone) would be
represented. Volunteer organizations, such as the Red Cross, often have permanent seats at the
table. Emergency operations centers normally have extensive communications capabilities to enable
them to interact simultaneously with a great number of organizations throughout a high-demand
period. Ideally, regional, state, and federal organizations would send representatives to this center if
they became involved in the response.1 State emergency officials may open their own command
center as well.
As soon as the emergency operations center opened, the incident commander at the scene of
a chemical terrorist attack would begin to funnel requests for resources through the center,
delegating the notifications, logistics, and coordination of incoming response units. For instance,
should the incident commander ask for extra help to contain the runoff from the decontamination
lines and buses to transport patients to the hospitals, the public works and environmental safety
departments would deliver crews, and the city might pull regular transit buses or activate contracts
with private transport companies. Anticipating a response of some duration, city managers might
ask one of the volunteer organizations to provide water and food for the rescuers on scene, as well
as for the hospital staffs. The emergency operations center would also organize humanitarian
assistance for victims (e.g., food, clothing, shelter). The emergency operations center would help
coordinate any evacuation that might be needed, or in the case of a biological attack, quarantine
activities. In these types of disasters, special attention would have to be given to mental health care
services not only for the victims but for the community at large.2 Another major function of the
emergency operations center is to provide information to the public and the media about the disaster
and the city's response to it. (continued, next page)
To supervise triage and initial medical care, MMRS teams include physicians and sometimes medical
toxicologists.82 Rapid administration of antidotes would be key to patient survival,83 but precision and
advanced medical expertise is required. Experience has repeatedly shown that serious consequences can
result when the wrong type or quantity of antidote is used. For example, the incorrect amount of dicobalt
vegetate given to individuals thought to have been poisoned by cyanide caused them to exhibit cobalt
82 Some cities are paging other toxicologists to the receiving hospitals, as well as to the city emergency operations
center. Interviews with author: Fire EMS Statistician (30 August 2000); Physician/Director of Hospital Disaster EMS (27 July
1999); Toxicologist, Poison Control Center (9 March 1999).
83 Sidell, Takafuji, and Franz, eds, Medical Aspects of Chemical and Biological Warfare, 32931; Richard J. Brennan,
Joseph F. Waeckerle, Trueman W. Sharp, and Scott R. Lillibridge, "Chemical Warfare Agents: Emergency Medical and
Emergency Public Health Issues," Annals of Emergency Medicine 34, no. 2 (August 1999): 201.
Chapter 6 Metropolis, USA: Progress, Pitfalls in Front-line Readiness 225
Box 6.3: Emergency Operations Center (continued)
City response agencies would first bring all of their own assets to bear, but as soon as officials
recognized that the disaster would outstrip their capacities, mutual aid agreements with neighboring
municipalities would be activated. The terms of fire mutual aid agreements differ from area to area,
sometimes involving hazmat as well as fire crews. In some locations, police and EMS also have
mutual aid agreements, in other cases not. Some cities also have standing aid arrangements with the
hazmat crews employed by private chemical companies.3 A couple of cities also reported cooperative
arrangements with local military bases that would enable them to tap into supplies, equipment, and
manpower.4 These regional assets were always described as essential components of success in
responding to a major disaster, in part because of the quick deployment time their proximity allowed
and in part because of prior responses that engendered high confidence that experienced, collegial
support would be provided.
NOTES
1. During a chemical terrorism drill in November 1997, one city challenged its major public utility company to maintain
service throughout the emergency, which led company officials to recognize the need to train and equip a team to operate in
warm zone conditions. Interview with author: Project Manager, Emergency Management Planning, Office of Emergency
Management (27 July 1999). Also on emergency operations center functions: Director, Emergency Services Department (18
May 2000); Division Chief, State Department of Emergency Management (3 May 2000); District Fire Chief, EMS Division
(2 March 2000); Project Manager, Emergency Management Planning (27 July 1999); Emergency Preparedness Director,
Office of Emergency Services (9 February 1999); Director, Office of Emergency Services (4 February 1999).
2. If a large number of fatalities were involved, the emergency operations center would help coordinate mortuary services and
grief counseling. Interviews with author: Director, Emergency Services Department (18 May 2000); District Fire Chief, EMS
Division (2 March 2000); Project Manager, Emergency Management Planning, Office of Emergency Management (27 July
1999); Emergency Preparedness Director, Office of Emergency Services (9 February 1999). For background on emergency
management practices as they apply to terrorism, see William L. Waugh, Jr., Terrorism and Emergency Management: Policy
and Administration (New York: Marcel Dekker, Inc., 1990).
3. Interviews with author: Fire EMS Statistician (30 August 2000); Project Manager, Emergency Management Planning,
Office of Emergency Management (27 July 1999); Chief of Response Division, State Department of Civil Emergency
Management (13 April 1999); Lieutenant/Hazmat Commander (10 March 1999); Special Projects Program Manager,
Department of Public Health (5 February 1999).
4. Interviews with author: Battalion Fire Chief/Special Operations Officer (25 May 2000); Director, Emergency Services
Department (18 May 2000).
poisoning. Also, when too much atropine is administered to patients suffering from nerve agent or
organophosphate exposure, they have to be put on respirators.84 While EMS crews have standardized
procedures for many types of injuries, such as immobilizing those with possible spinal cord damage, a
consensus is still forming as to the best practices for the field care of people exposed to super toxic
chemicals. The lack of pre-hospital treatment protocols has caused no end of frustration and confusion
locally. A case in point was the significant controversy over civilian use of the Mark 1 kits, which were
84 Timothy C. Marrs, "National Consequence Management Concepts and Plans for Chemical and Biological Incident
Response," in Proceedings of the Seminar of Responding to the Consequences of Chemical and Biological Terrorism, page
314. An atropine overdose patient may need to be on a respirator for several days. From 18 to 28 February 1991, Iraq bombed
Israel with thirty-nine Scud missiles, and many thought they were armed with chemical agents. In the vicinity of Tel Aviv, 230
overdoses of atropine occurred during this timeframe. Guidelines for Mass Casualty Decontamination, 37, note 10.
226 Ataxia: The Chemical and Biological Terrorist Threat and the US Response
designed by the military for battlefield use to counteract severe nerve agent poisoning. Absent guidelines,
cities were adopting different policies.85
Emergency response personnel expressed differing philosophies about when to initiate medical
treatment of victims, depending in no small part upon whether their EMS squads were trained and equipped
to operate in the warm zone. According to one approach, EMS personnel in regular work clothing would
attend to victims after they were fully decontaminated.86 A second approach would be more aggressive, with
EMS personnel in protective garb, partnering with hazmat specialists in the contaminated area. Some cities
would even call upon their EMS staffs to help with rescue operations; others would assign their paramedics
and EMTs to conduct preliminary triage, begin medical treatment before decontamination if warranted, and
assist and evaluate the medical status of victims throughout the decontamination process. Figure 6.3 portrays
this forward triage approach as it pertains to nerve agent casualties. Patients would then move to the formal
triage area for additional medical treatment, as appropriate, and priority staging to ambulances.87 The
advantage to forward triage is that medical intervention occurs as soon as possible, all the more important
85 Mark 1s contain a pair of auto-injectors with atropine and pralidoxime chloride, or 2-PAM. The doses in these
injectors are pre-measured for physically fit soldiers, but children, the elderly, and pregnant women could be felled in a terrorist
attack. Some cities are therefore reserving Mark 1s solely for their affected first responders, who are more likely to match the
military weight and fitness profile. Some cities bought vials of atropine so that doses can be adjusted for civilians. Interviews
with author: Police Sergeant (2 April 1999); Emergency Preparedness Director, Office of Emergency Services (9 February 1999).
Others, however, developed pre-hospital protocols for the Mark 1s. In some jurisdictions, only paramedics are authorized to use
these kits; in others, EMTs are authorized as well. As to worries about whether the kits are appropriate for civilians, one
responder observed that if victims are exhibiting symptoms, the fine tuning of treatment could be done by physicians, if the EMS
crews could keep them alive. Interviews with author: EMS Chief, Emergency Services Department (21 September 2000);
Deputy Director, Office of Emergency Management (26 May 2000); Battalion Fire Chief, Special Operations (25 May 2000);
Director, Emergency Services Department (18 May 2000); Paramedic (12 May 2000); MMRS Coordinator, Fire Department (9
May 2000); Registered Nurse/Emergency Planner, Public Health Department (7 April 2000); Fire Captain/Assistant Emergency
Management Coordinator (5 January 2000); Physician/Associate Medical Director, Fire EMS Division (27 July 1999). On
having developed pre-hospital protocols for several chemical agents: Fire EMS Statistician (30 August 2000).
86 In some instances, this approach is being used out of choice, as EMS supervisors see no reason to have their
personnel operate in a contaminated environment. In other cities, stationing EMS crews only in the cold zone is a necessity,
because cities have not yet been able to outfit and train their EMS personnel to operate in protective gear. Interviews with
author: Director, County Emergency Management (21 September 2000); Hazmat Coordinator/Instructor (8 September 2000);
Director, Emergency Services Department (18 May 2000); Fire Chief (15 May 2000); Paramedic (12 May 2000); MMRS
Coordinator, Fire Department (9 May 2000); Emergency Management Specialist, Office of Emergency Management (9 May
2000); District Fire Chief, EMS Division (2 March 2000); Registered Nurse/Chief, EMS Division, State Department of Public
Health (3 February 2000); Battalion Fire Chief (19 January 2000); Battalion Fire Chief/Emergency Services Administrator (15
November 1999); Paramedic Operations Supervisor, Paramedic Division (9 March 1999).
87 Several cities plan to employ forward triage. Interviews with author: EMS Chief, Emergency Services Department
(21 September 2000); Deputy Director, Office of Emergency Management (26 May 2000); Battalion Fire Chief, Special
Operations (25 May 2000); Registered Nurse/Emergency Planner, Public Health Department (7 April 2000); Deputy
Coordinator, Fire Emergency Preparedness and Disaster Services (3 February 2000); Fire Captain/Assistant Emergency
Management Coordinator (5 January 2000); Physician/EMS Medical Director (13 November 1999); Fire Captain, EMS Division
(27 July 1999); Fire Chief (14 June 1999). A Defense Department report cautions that non-ambulatory patients showing
significant signs of exposure should be the only ones to receive medical treatment prior to decontamination. In cases of nerve
agent exposure, Mark 1 kits can be administered in the hot zone, after which victims should be quickly removed from the
contaminated area. Guidelines for Mass Casualty Decontamination, 21.
Chapter 6 Metropolis, USA: Progress, Pitfalls in Front-line Readiness 227
Box 6.4: Local Worries About Help From Outside the Region
In contrast to the confidence that city officials expressed about regional rescue assets stepping
in to help them after an unconventional terrorist attack, virtually every local official interviewed had
major reservations about the ability of federal and even state assets to arrive in sufficient time to impact
the outcome of a chemical terrorist attack response. They were also seriously concerned whether the
federal government could quickly deliver enough medical manpower to help after a biological attack.
Whereas rescuers can recover victims days after earthquakes and tornadoes, the lifesaving window of
opportunity for a chemical attack is much, much briefer. The locals repeatedly pointed out the
difference between the deployment times promised for these teams and reality. Several interviewees,
veterans of Urban Search and Rescue task forces and Disaster Medical Assistance Teams, knew full
well the delays in deploying these teams. None of the specialized federal or state teams, they said,
would have lifesaving applicability after a chemical terrorist attack unless they were pre-deployed. To
say the least, interviewees were vexed about the funds "wasted" on creating new federal and state teams
and money frittered away on enhancing other federal teams for rescue missions they cannot achieve.
Conversely, they worried that insufficient funding and use of the civilian medical response system
meant that the medical cavalry might not come through when they were needed most.1
Far and away the most criticized of the newcomers were the National Guard's Weapons of
Mass Destruction Civil Support Teams, at first known as the RAID (Rapid Assessment and Initial
Detection) teams. The National Guard can be called out by a state governor, but can also be
federalized. The locals viewed the resources being poured into the RAID teams as nothing short of
scandalous, characterizing this effort as a job employment program. Locals that saw RAID squads in
action rated them as bulldozing amateurs. To illustrate the point, a RAID team pushed aside local
rescuers in the Portsmouth segment of the mid-May 2000 Topoff drill, where a terrorist attack with the
chemical agent mustard was simulated. Yet, this particular team lacked the technical expertise to
understand the minimal hazard posed by mustard on a chilly, forty-nine degree day.2 Incident
commanders want to be able to rely on the help that arrives, not worry about deficiencies in training and
experience that could hinder or jeopardize their own personnel. RAID teams would not accrue
invaluable mission experience until a unconventional attack occurs, and trials by fire are a recipe for
failure. Similar concerns were voiced about other federal squads that rarely see real action, but in
particular, local responders heaped ridicule on the RAID teams: "They're helping me?" scoffed one fire
chief.3 To a person, however, the local officials welcomed the Guard in its traditional support role. The
locals anticipate asking the National Guard to help only with cots, water supplies, law enforcement
support, and other logistical matters.4
City emergency managers and responders expressed a great deal of apprehension that just as
they were beginning to get a handle on the disaster, they would be bombarded with incoming federal
teams. Although local officials had heard federal authorities state that no help would be sent unless
requested, each dismissed such claims because they had seen the federal teams shove vigorously to
participate in mere exercises, much less in a real event. The locals noted that the officers and
bureaucrats who created these teams would deploy to justify their existence. Once on the ground, local
authorities expected the pushing to continue. With a mixture of chagrin and amusement, they related
tales of federal squads scrapping with each other for tasks, brandishing every conceivable kind of
gizmo. Federal protestations to the contrary, locals have also experienced outside teams telling them
what to do in their own city, despite their utter lack of knowledge of local capabilities and
circumstances. Local rescuers therefore predicted that the state and federal teams would jam them up so
completely that they could hardly function, creating another disaster of sorts.5 Only half facetiously,
one city emergency manager stated that once the disaster scene was cleared, his first order of business
would be to station police at the city boundaries, guns pointed outward, to keep all of these "helpers"
from overrunning the city hours later.6 (continued, next page)
228 Ataxia: The Chemical and Biological Terrorist Threat and the US Response
Box 6.4: Local Worries (continued)
The locals were not alone in this forecast: One senior federal bureaucrat described how the sky
would be "black with the incoming aircraft filled with helpers."7 The locals worried that once the
federal teams arrived they would have to expend more time and energy managing the federal assets than
the crisis at hand. Instead of weaving into the local emergency operations center, multiple federal
command posts would be established. To keep tabs on what these so-called helpers were doing, local
officials would have to send representatives to the federal command posts, an additional drain on
already depleted city emergency response personnel.8 While they were extremely skeptical that federal
teams would be disciplined enough not to barge in after a chemical disaster, local officials hoped that
outside teams would at least stage at the nearest military base. With the exception of FBI personnel,
who would be pursuing the criminal investigation, the only non-local expertise the city officials could
truly foresee needing in the short term was in area decontamination, if their regular contractors refused
to take the assignment. In other words, locals fully expect to ask that these state and federal squads to
return home without any ever seeing the disaster scene. If a biological attack took place, however, they
simply hope against hope that a federal medical aid system never tested in such a crucible would be able
to get significant medical assets there in time.9
NOTES
1. Interviews with author: General Manager, Emergency Department (22 September 2000); Hazmat Coordinator/Instructor (8
September 2000); Fire EMS Statistician (30 August 2000); Medical Toxicologist/Poison Control Center Director (13 June
2000); Deputy Director, Office of Emergency Management (26 May 2000); Battalion Fire Chief/Special Operations Officer (25
May 2000); Director, Emergency Services Department (18 May 2000); Division Chief, State Department of Emergency
Management (3 May 2000); Detective/Bomb Squad (19 January 2000); Battalion Fire Chief (19 January 2000); Chief, County
Fire Department (9 September 1999); Project Manager, Emergency Management Planning (27 July 1999); Director of Hospital
EMS and Disaster Medicine (19 April 1999); Fire Commander (19 April 1999); EMS Superintendent-in-Chief (24 March
1999); Police Lieutenant (23 March 1999); Assistant Director, Office of Emergency Management (23 March 1999); Paramedic
Operations Supervisor (9 March 1999); Lieutenant/Hazmat Commander (10 March 1999); Fire Captain, Hazmat Unit (9
February 1999); Battalion Fire Chief (9 February 1999); Emergency Preparedness Director, Office of Emergency Services (9
February 1999); Fire Lieutenant (5 February 1999); Police Captain/Firing Range Director (5 February 1999); Registered
Nurse/Hospital Disaster Coordinator (4 February 1999); Paramedic/Emergency Planner, Public Health Department (4 February
1999); Director, Office of Emergency Services (4 February 1999). Often, the delay is not in the team reporting to the airport,
but in getting them and their equipment aboard commercial flights.
2. Interviews with author: Hazmat Coordinator/Instructor (8 September 2000); former EMS Supervisor/Paramedic (12 July
2000). Another National Guard team was so unfamiliar with its equipment that in another drill several hours passed before they
were ready to enter the contaminated zone. Then, the Guard team tried to give the city responders directions about possible
plume repercussions, but they lacked the knowledge of how the chemical plume would effect the area depending upon the
population at different times of day. Interview with author: Detective/Bomb Squad member (19 January 2000); Battalion Fire
Chief (19 January 2000).
3. Emphasis reflects the incredulous tone of the comment. Interview with author: Chief, County Fire Department (9 September
1999). Similar reactions to the RAID teams were given by: Hazmat Coordinator/Instructor (8 September 2000); former EMS
Supervisor/Paramedic (12 July 2000); Firefighter/Hazmat Instructor/Paramedic (28 June 2000); Battalion Chief (19 January
2000); Fire Commander (19 April 1999); Hazmat Materials Specialist (19 April 1999); Director of Hospital EMS and Disaster
Medicine (19 April 1999); Lieutenant/Hazmat Commander (10 March 1999); Lieutenant/Hazmat Commander (10 March
1999); Emergency Planner, Office of Emergency Management (8 March 1999). Similar tales and views were expressed by:
Fire EMS Statistician (30 August 2000); EMS Supervisor (20 May 1999); Deputy Director, Office of Emergency Management
(26 May 2000); Division Chief, State Disaster Medical Services Division (15 February 2000); Detective/Bomb Squad member
(19 January 2000); Battalion Fire Chief (15 November 1999); Battalion Fire Chief/Emergency Services Administrator (15
November 1999); Project Manager, Emergency Management Planning (27 July 1999); Police Lieutenant (23 March 1999);
Fire Captain, Hazmat Unit (9 February 1999); Battalion Fire Chief (9 February 1999); Emergency Preparedness Director,
Office of Emergency Services (9 February 1999); Director, Office of Emergency Services (4 February 1999). For yet another
negative review of the RAID teams, see General Accounting Office, Use of National Guard Response Teams Is Unclear.
4. Ibid. (continued, next page)
Chapter 6 Metropolis, USA: Progress, Pitfalls in Front-line Readiness 229
Box 6.4: Local Worries (continued)
5. "Everybody and their brother wants to go to the scene to justify their response capability or some little whiz-bang toy that
they have developed and want to use." Interview with author: Director of Hospital EMS/Disaster Medicine (19 April 1999).
Two officials described federal teams arriving in their city with price tags still on their gear, then coming close to a fist-fight
over which team would get to analyze a sample that common sense told the locals was innocuous. Interviews with author:
Lieutenant/Hazmat Commander (10 March 1999); Emergency Planner, Office of Emergency Management (8 March 1999).
Other tales of this nature were recalled by: General Manager, Emergency Department (22 September 2000); Hazmat
Coordinator/Instructor (8 September 2000); Fire EMS Statistician (30 August 2000); former EMS Supervisor/Paramedic (12
July 2000); Deputy Director, Office of Emergency Management (26 May 2000); EMS Supervisor (20 May 1999); Division
Chief, State Disaster Medical Services Division (15 February 2000); Detective/Bomb Squad member (19 January 2000);
Battalion Fire Chief (15 November 1999); Battalion Fire Chief/Emergency Services Administrator (15 November 1999);
Project Manager, Emergency Management Planning (27 July 1999); Police Lieutenant (23 March 1999); Fire Captain,
Hazmat Unit (9 February 1999); Battalion Fire Chief (9 February 1999); Director, Office of Emergency Services (4 February
1999). On how squabbles between local, federal, and state officials can cost lives, Osterholm and Schwartz, Living Terrors,
179.
6. Interview with author: Director, Office of Emergency Services (2 April 1999).
7. Interview with author: Senior official, Health and Human Services (HHS) Department (6 May 2000).
8. "The federal government doesn't understand the concept of a unified command." Director, Office of Emergency Services
(2 April 1999). Acknowledging the problem of multiple federal command posts, Senior official, HHS Department (6 May
2000). Also on the headache of interacting with the various federal commands, Chief of Response Division, State
Department of Civil Emergency Management (13 April 1999); Police Lieutenant (23 March 1999).
9. Federal assets were staged in this manner after the Oklahoma City bombing and in natural disasters, such as Hurricanes
Opal and George. Many teams were sent home without being pulled into service. Interview with author: Director of Hospital
EMS and Disaster Medicine (19 April 1999). Cities often have companies on contract to clean up sites after a hazmat
incident, but more than one city reported being unable to locate a contractor willing to take on this type of a job. Expecting to
ask for decontamination assistance: Director, Emergency Management Division, County Department of Public Safety (19
September 2000); District Fire Chief, EMS Division (2 March 2000); Battalion Fire Chief (17 November 1999); Emergency
Manager, Office of Emergency Management (17 May 1999); Fire Commander (19 April 1999); Chief, County Fire
Department (9 September 1999). On worries about the timeliness and quantity of federal medical aid: Registered
Nurse/Chief, EMS Division, State Department of Public Health (3 February 2000); Director of Hospital EMS and Disaster
Medicine (19 April 1999); Police Lieutenant (23 March 1999); EMS Superintendent-in-Chief (24 March 1999); Physician,
Hospital Department of Emergency Medicine (24 March 1999); former State Epidemiologist (18 August 2000); Physician,
Division of Disease Control, Public Health Department (8 August 2000); Fire EMS Statistician (30 August 2000);
Emergency Preparedness Director, Office of Emergency Services (9 February 1999); Senior CDC Official (29 August 2000);
Registered Nurse/Hospital Disaster Coordinator (4 February 1999).
because chemical agents can kill within minutes and decontamination can be a slow process. According to
one source, decontamination could delay medical intervention by twelve to twenty-five minutes.88 However,
this forward triage approach requires EMS crews to don protective clothing, unfamiliar territory for many.
A study with twenty paramedics, summarized in table 6.1, shows that EMS personnel can still perform
procedures that demand dexterity in this gear, albeit not as quickly.
88 S. Dyer et al., "Efficiency of Civilian Paramedics at Performing Medical Interventions While in Chemical Protective
Gear," Presentation Abstract, Clinical Toxicology 36, no. 5 (1998): 477.
Figure 6.3: Medical Management for Nerve Agent Casualties, Employing Mark 1 Kits*
Non-ambulatory, in respiratory
Victim Signs, distress, agitated, and other Ambulatory, exhibiting Victim exhibiting no
Not moving
Symptoms symptoms(salivation, cramps, limited signs of signs, symptoms of
vomiting, tearing, urinating, respiratory distress nerve agent exposure
defecating, muscle twitching)
Noxious Stimulus
Triage performed in Initial triage in warm
zone by trained
Triage hot zone by trained personnel in
Evaluation personnel in Observation Observation
appropriate appropriate protective
protective gear, gear
still no movement
YELLOW
RED tagged in cold GREEN
Triage tagged before tagged in cold
BLACK zone, after
Priority decontamination zone, after
(non-viable)** decontamination
(critical to severe (moderate decontamination
exposure) exposure) (asymptomatic)
Prior to
decontamination:
administer 3
Initial None sequential atropine Observation only,
Treatment injectors, then 3 After decontamination: unless symptoms
sequential 2-PAM administer 2 atropine develop
injectors*; write "A" injectors, then 1
and time of 2-PAM injector*
treatment on tag
Monitor Time None 3 to 5 minutes 5 to 10 minutes 10 to 15 minutes
If moderate respiratory
If severe respiratory If mild respiratory
distress persists, distress or other
Subsequent distress persists,
None administer 1 atropine
administer another symptoms develop,
Treatment injector, write "A" on tag
atropine injector and administer 1
and note time; if
note time on tag; no atropine injector;
condition deteriorates
additional 2-PAM write "A" on tag
with severe respiratory
permitted* and note time;
distress, administer re-evaluate and,
2 more 2-PAM if condition
injectors, and upgrade deteriorates,
to red tag* upgrade to yellow
or red tag.
*The Mark 1 atropine autoinjector contains a 2 milligram dose, the 2-PAM (pralidoxime chloride) injector contains a 600 milligram dose. While the maximum
dose for 2-Pam is 1.8 total grams, or three injectors, there is no maximum dose for atropine.
**Since severe nerve agent exposure makes victims stop breathing, one medical toxicologist cautioned against quick black tagging of non-breathing victims.
Instead, a Mark 1 kit should be administered to attempt to revive such victims. If there is not response to resuscitation efforts, then a black tag is appropriate.
Interview with author: Toxicologist/Poison Control Center Director (13 June 2000).
Source: Hazmat Medical Management Protocol, Medical Director, EMS Division, Fire Department (n.d.).
Chapter 6 Metropolis, USA: Progress, Pitfalls in Front-line Readiness 231
Table 6.1: Efficiency of Paramedics Performing Medical Interventions in Standard Uniform Versus
Level B Chemical Protective Gear
Procedure Standard Uniform Chemical Protective Equipment**
Endotracheal intubation*** 23.3 seconds +/- 4.91 seconds 26.58 seconds +/- 6.75 seconds
Intramuscular injection 42.3 seconds +/- 10.79 seconds 50.23 seconds +/- 12.13 seconds
* Study performed with two physicians using a crossover design to evaluate twenty civilian paramedics
performing two procedures on mannequins. A paired test was employed to compare performance in standard
uniform and chemical protective gear. Results for intubation were p = 0.02; for intramuscular injection,
p = 0.004.
** Self-contained breathing apparatus, butyl suits, and nitrile gloves.
*** Two recognized esophageal intubations occurred in chemical protective gear, one in standard uniform.
Source: S. Dyer, K. Brinsfield, A. Woolf, D. White, R. Haley, "Efficiency of Civilian Paramedics at
Performing Medical Interventions While in Chemical Protective Gear," Presentation Abstract, Clinical
Toxicology 36, no. 5 (1998): 477.
Cities using the forward triage approach were putting Mark 1s and other treatments on their
ambulances, hazmat trucks, as well as on some fire engines and at hospitals.89 This strategy is not without
its downside, however, because these chemical antidotes have both limited applications and shelf lives. To
illustrate the point, one city placed cyanide kits on all of its ambulances as a precaution during the 1982
Tylenol poisoning scare, but these kits were never used, expired, and were never replaced.90 Some cities
were purchasing the powdered form of the nerve agent antidote atropine. The powdered variant has no
expiration date, which takes the fiscal sting out of stocking a single-purpose drug, but some advise against
relying on powdered atropine when time is of the essence, particularly for the pre-hospital treatment of
patients.91 Perhaps not surprisingly, given the lack of consensus on several matters, numerous cities had not
89 One approach is to put 20 percent of the antidotes on the front-line units, 20 percent in reserve on the MMRS trailer,
and spread 40 percent among different receiving hospitals. Interview with author: Physician/EMS Medical Director (13
November 1999). Also noting placement of antidotes on front-line units in interviews with the author: Deputy Director, Office
of Emergency Management (26 May 2000); Battalion Fire Chief, Special Operations (25 May 2000); Paramedic (12 May 2000);
Fire Captain, EMS Division (27 July 1999); EMS Superintendent-in-Chief (24 March 1999); Emergency Preparedness Director,
Office of Emergency Services (9 February 1999); Special Projects Program Manager, Department of Public Health (5 February
1999). Some of these medications are controlled substances, so one city opted against putting medical antidotes in the kits that
its MMRS members carry in their cars because of concerns that these drugs might be stolen. Interview with author: Emergency
Management Specialist, Office of Emergency Management (9 May 2000).
90 Interview with author: Registered Nurse/Chief, EMS Division, State Department of Public Health (3 February 2000).
Similarly, another EMS supervisor noted that his city's ambulances used to carry some respiratory and protective gear, but these
items were very seldom used and had been misplaced over the years. Interview with author: District Fire Chief, EMS Division (2
March 2000). See chapter 5 for discussion of the aggravation surrounding the required purchase of large numbers of Mark 1 kits
by cities participating in the MMRS program.
91 In some locations, paramedics are accustomed to reconstituting drugs, but extra precautions must be taken when
reconstituting atropine. Exposure to the powdered form of atropine can be lethal. Interviews with author: Registered
Nurse/Chief, EMS Division, State Department of Public Health (3 February 2000); Physician/Associate Director, Hospital
Department of Emergency Medicine (9 March 1999); Emergency Planner (8 March 1999).
232 Ataxia: The Chemical and Biological Terrorist Threat and the US Response
established pre-hospital chemical agent exposure treatment protocols.92 A 25-member expert panel
sponsored by the Health and Human Services Department was developing consensus pre-hospital and
hospital medical protocols, but by mid-2000 only a draft protocol for chlorine exposure victims was
available.93 The completion of such protocols would no doubt be of great utility to EMS personnel attending
to critical patients in the most difficult of circumstances.
A chemical incident with numerous casualties would preoccupy a city's EMS resources for quite
some time. In the event of such an attack, one city arranged for the EMS crew from neighboring areas to
cover regular 911 calls.94 EMS personnel in large cities attend to hundreds, even thousands, of 911 calls
daily. Emergency planners in other locations had not made supplemental arrangements to provide EMS
service for the routine baby deliveries, car accidents, and heart attacks that would continue in the city during
post-attack rescue operations.
Crisis Management at the Hospitals
When it comes to the ability of the nation's hospitals to handle large numbers of casualties exposed
to hazardous materials, the shortcomings are glaring if one talks to hospital staffers or examines the
regulations and the professional literature. First, accidents with hazardous materials occur frequently, to the
tune of 60,500 incidents nationwide every year, over 2,550 of which result in injury or death.95
Notwithstanding EMS policies that mandate decontamination prior to ambulance transport, over 80 percent
of these casualties arrive at hospitals still contaminated.96 While a significant residual concentration of
92 Interviews with author: District Fire Chief, EMS Division (2 March 2000); Registered Nurse/Chief, EMS Division,
State Department of Public Health (3 February 2000); Battalion Fire Chief (19 January 2000).
93 This panel, staffed out of the Rocky Mountain Poison and Drug Center, met for the first time in March 1999 and
conducts an extensive literature review in advance of each draft protocol. Abbreviated pre-hospital and hospital protocols will be
developed for several major warfare agents or agent categories, including nerve agents, mustard gas, phosgene, and cyanogen
agents. Interview with author: Toxicologist, Poison Control Center (15 June 2000).
94 Interview with author: Paramedic Operations Supervisor (9 March 1999).
95 These figures represent an average over a ten-year time period and take into account on-site accidents at facilities and
with the transit of chemical substances. The 600K Report: Commercial Chemical Incidents in the United States 19871996,
Special Congressional Summary (Washington, DC: US Chemical Health and Safety Investigation Board, 24 February 1999), 10.
This report, incorporating statistics collected by five separate agencies, also contains a list of the chemicals most frequently
involved.
96 Interviews with author: Medical Toxicologist/Poison Control Center Director (13 June 2000); Physician/Director of
Hospital Disaster EMS (27 July 1999); Director of Hospital EMS and Disaster Medicine (19 April 1999); Physician, Hospital
Division of Emergency Medicine (24 March 1999); Registered Nurse/Hospital Disaster Coordinator (4 February 1999). The
author was told eye-opening tales about hospital contamination. In one, two patients arrived via helicopter at a hospital,
contaminating not only their transport, but the hospital elevators, corridors, and emergency department. In another, an EMS
crew delivered a critical patient to the emergency department. So much hazardous liquid had dripped from the patient during
transport that the ambulance, left running just outside during the delivery, exploded. Interview with author: Fire Chief (14 June
1999). On decontaminate-before-transport policies: Former EMS Supervisor/Paramedic (12 July 2000); Emergency
Chapter 6 Metropolis, USA: Progress, Pitfalls in Front-line Readiness 233
chemicals may not remain on them at that juncture, the contamination threat must still be isolated and the
patients decontaminated and treated.97 Second, despite these statistics, the nation's hospitals are not required
to have a standing capacity to decontaminate a few, much less large numbers of patients. The Joint
Commission on Accreditation of Healthcare Organizations (JCAHO) and OSHA govern hospital preparations
in that regard, with the former stipulating that hospitals maintain a decontamination capability without further
specification. Hospitals have typically interpreted this standard to mean they must be able to decontaminate
one person.98 Finally, apparently neither JCAHO nor OSHA ensures that hospitals meet even this minimal
standard. None of the hospital personnel interviewed could recall JCAHO inspectors ever asking them or
their colleagues to demonstrate an ability to use decontamination equipment.99
Not surprisingly in this regulatory environment, whatever decontamination equipment a hospital has
often remains in its original shipping box.100 A survey of emergency hospitals in the state of Washington
Management Specialist, Office of Emergency Management (9 May 2000); EMS Superintendent-in-Chief (24 March 1999);
Emergency Planner (8 March 1999).
97 Jeffrey L. Burgess, Mark Kirk, Stephen W. Borron, and James Cisek, "Emergency Department Hazardous Materials
Protocol for Contaminated Patients," Annals of Emergency Medicine 34, no. 2 (August 1999): 207.
98 JCAHO gives hospitals the vague directive that their disaster plans must identify "facilities for radioactive or
chemical isolation and decontamination." See Standard EC.1.6, JCAHO, Comprehensive Accreditation Manual for Ambulatory
Care, Environment of Care Chapter. Internet: http://www.jcaho.org/standard/ecer.html. Downloaded 7 August 2000. OSHA
Regulation1910.120(q)(6) requires operations level hazmat training at a minimum, which includes at least eight hours of training
or demonstration of a matching level of proficiency, as well as an annual refresher course. Hospitals and Community Emergency
ResponseWhat You Need to Know, (Washington, DC: US Department of Labor, Occupational Safety and Health
Administration, 1997).
99 One physician said he and his colleagues have called OSHA to inquire about the regulation and its enforcement on
numerous occasions, and the OSHA bureaucrats gave him no information or guidance, other than to refer back to the regulation.
Interview with author: Physician/Director of Hospital Disaster EMS (27 July 1999). JCAHO evaluates hospitals every three
years and has the authority to suspend or close them if they fail to meet standards. One interviewee recalled that JCAHO would
occasionally ask the day shift to see the decontamination equipment. Interview with author: Registered Nurse/Chief, EMS
Division, State Department of Public Health (3 February 2000). Others noted that inspectors would occasionally ask to see
training records for individuals and how the last contaminated patients were treated, exploring whether the practice was in line
with the hospital's policies disaster plans and procedures. Interviews with author: Fire/Rescue Instructor, former Director,
Hospital Security (21 August 2000); Emergency Planner, Hospital Health Maintenance Organization (15 August 2000); Medical
Toxicologist/Poison Control Center Director (13 June 2000); Physician/EMS Medical Director (13 November 1999); Associate
Hospital Administrator/Registered Nurse (13 November 1999). Others commenting on JCAHO's failure to check
decontamination capabilities: Physician, Hospital Division of Emergency Medicine (31 May 2000); Paramedic (12 May 2000);
Registered Nurse/Emergency Planner, Public Health Department (7 April 2000); Director of Hospital EMS and Disaster
Medicine (19 April 1999). Only one person interviewed had heard of JCAHO asking for a demonstration. Interview with
author: Commander, US Public Health Service (3 July 2000).
100 One city's premier university hospital, purportedly the medical facility in that area best prepared to handle
contaminated patients, refused to accept an incoming patient who may have been exposed to anthrax. The hospital staff feared
that this individual would force the closure of the emergency department, despite being told that this patient had already been
thoroughly decontaminated. Later, hospital officials quietly conceded that they did not want to break the seal on their
decontamination room. Interview with author: District Fire Chief, EMS Division (2 March 2000). Note that this incident speaks
also to the lack of knowledge among health care providers about relative contamination threats. Secondary contamination from a
biological agent is much less likely than from a chemical agent. Barrier precautions are considered sufficient for many biological
agent situations. See table 6.2 for specific details.
234 Ataxia: The Chemical and Biological Terrorist Threat and the US Response
showed that over a third of those responding did not have any designated decontamination facility.
Moreover, in the five years preceding this 1997 survey, twelve of the hospitals had been contaminated at least
once by incoming patients and therefore compelled to evacuate part of the hospital.101 Interviews for this
report provided similarly discouraging statistics. What little capacity existed was not regularly drilled.102
In short, "many [hospitals] are poorly prepared" to decontaminate even one or two patients, even those with
"well-run, full-service emergency departments."103 Another state's 1999 survey found that while the day shift
might have some knowledge of decontamination policies and procedures, the evening, night, and weekend
shifts in hospitals were not at all versed in these matters.104
These circumstances present something of a dilemma for the hospital personnel and emergency
planners plotting strategy for the contaminated casualties that might flood their facilities after a chemical
terrorist attack. Hospitals in some cities have stated that they plan to keep their doors open and operate as
normal.105 In many other cities, however, the first action that hospitals said they would take after notification
of a major hazmat event was to lock their doors and post security at all entrances. This lockdown policy was
matter-of-factly stated. The priority from the hospitals' perspective is to prevent the compromise of the
101 The survey consisted of ninety-two hospitals and three clinics at a time when there were 120 hospitals statewide.
Although forty-seven reported that they could only receive decontaminated patients, fifty-six hospitals stated they had
decontamination facilities, twenty-three of which were outside. Twenty-two of the hospitals had separate ventilation and water
containment capabilities. Six hospitals classified themselves as unable to receive any exposed patients, and thirty-nine had no
decontamination facilities. Jeffrey L. Burgess, Griffith M. Blackmon, C. Andrew Brodkin, and William O. Robertson, "Hospital
Preparedness for Hazardous Materials Incidents and Treatment of Contaminated Patients," Western Journal of Medicine 167, no.
6 (December 1997): 3879.
102 Of the twenty-two hospitals in one county, only three have showers with a one to two person capacity. The rest
have nothing. Interview with author: Paramedic (12 May 2000); EMS Specialist/Paramedic (12 May 2000). Also on the low
level of hospital decontamination capacity: Medical Toxicologist/Poison Control Center Director (13 June 2000); Physician,
Hospital Division of Emergency Medicine (31 May 2000); Registered Nurse/Emergency Planner, Public Health Department (7
April 2000); District Fire Chief, EMS Division (2 March 2000); Registered Nurse/Chief, EMS Division, State Department of
Public Health (3 February 2000); Fire Captain/Assistant Emergency Management Coordinator (5 January 2000); Battalion Fire
Chief (17 November 1999); Director of Hospital EMS and Disaster Medicine (19 April 1999); Physician, Hospital Department
of Emergency Medicine (24 March 1999); Battalion Fire Chief/EMS Supervisor (8 February 1999); Registered Nurse/Hospital
Disaster Coordinator (4 February 1999); Paramedic/Emergency Planner, Public Health Department (4 February 1999). In a few
cases, one or a couple of hospitals had taken steps to improve decontamination capabilities. Interviews with author: Director,
Emergency Management Division, County Department of Public Safety (19 September 2000); Director, Office of Emergency
Preparedness (19 September 2000); Emergency Planner, Hospital Health Maintenance Organization (15 August 2000);
Physician, Hospital Division of Emergency Medicine (31 May 2000); Emergency Management Specialist, Office of Emergency
Management (9 May 2000).
103 Anthony G. Macintyre et al., "Weapons of Mass Destruction Events With Contaminated Casualties: Effective
Planning for Health Care Facilities," Journal of the American Medical Association 283, no. 2 (12 January 2000): 243.
104 Interview with author: Registered Nurse/Chief, EMS Division, State Department of Public Health (3 February
2000).
105 Interviews with author: Director, Emergency Services Department (18 May 2000); Paramedic (12 May 2000);
Registered Nurse/Emergency Planner, Public Health Department (7 April 2000).
Chapter 6 Metropolis, USA: Progress, Pitfalls in Front-line Readiness 235
hospital due to contamination, which would compound the problem.106 Patients would have to be evacuated
from any section of a hospital that was contaminated and those areas sterilized before routine operations
could resume. Depending on the extent of the contamination, a few hours to more than a day could transpire
before the affected section(s) of the hospital could be reopened.107
One of the foibles of lockdown plans was that few hospitals had a security staff large enough to
contend with a major crush of ambulatory injured or panicked people. Therefore, hospitals said they would
erect external barriers and call for police assistance if swelling crowds became unruly. From city to city,
police departments differed in their willingness to lend hospitals a hand with security.108 Police, however,
would have a need to interview and gather evidence from these people, who could be crime witnesses. If
106 Some cities have hospital call-down lists to warn that a chemical attack has occurred so they can lock down.
Interviews with author: Physician/University Hospital Department of Emergency Medicine (20 September 2000); Police
Lieutenant, Tactical Support Office (18 September 2000); Battalion Fire Chief, Special Operations (25 May 2000); Police
Lieutenant (23 March 1999); Emergency Planner (8 March 1999). Also on lockdown plans: Hazmat Coordinator/Instructor (8
September 2000); Emergency Planner, Hospital Health Maintenance Organization (15 August 2000); Medical
Toxicologist/Poison Control Center Director (13 June 2000); Physician, Hospital Division of Emergency Medicine (31 May
2000); Fire Sergeant (9 May 2000); Emergency Management Specialist, Office of Emergency Management, (9 May 2000);
Registered Nurse/Chief, EMS Division, State Department of Public Health (3 February 2000); Physician/Hospital Department of
Emergency Medicine (15 June 1999); Director of Hospital EMS and Disaster Medicine (19 April 1999); EMS Superintendent-
in-Chief (24 March 1999); Physician/Associate Director, Hospital Department of Emergency Medicine (9 March 1999). See
also, Steve Salvatore, "US Hospitals Unprepared for Chemical, Biological Terrorism, Study Says," CNN.com (11 January 2000).
Internet: http://www.cnn.com/2000/HEALTH/01/11/bioterrorism.02. Downloaded 25 May 2000. Some hospitals have
lockdown plans for other purposes, for example calling a "code pink" if someone attempts to abduct a baby from the maternity
ward. Some hospitals have computerized control of all access points and can enact a lockdown swiftly. To other hospitals, the
concept of a lockdown is alien. One hospital drilled lockdown for the first time during its functional exercise, and seventy
minutes passed before the security staff declared the facility closed. Afterwards, drill referees found three doors open. Interview
with author: Fire Captain/Assistant Emergency Management Coordinator (5 January 2000). On the difficulty of executing a
lockdown policy, see also, Thomas Inglesby, Rita Grossman, and Tara O'Toole, "A Plague on Your City: Observations from
TOPOFF," Biodefense Quarterly 2, no. 2 (September 2000). Internet: http://www.hopkins-biodefense.org/pages/news/
quarter.html. Downloaded 12 October 2000.
107 Scrubbing down a contaminated room takes roughly twenty minutes, so if a large emergency department were
contaminated, roughly a day could be required to sterilize and re-open just that department. Interviews with author: former EMS
Supervisor/Paramedic (12 July 2000); Physician, Hospital Division of Emergency Medicine (31 May 2000). See also, Burgess et
al., "Emergency Department Hazardous Materials Protocol for Contaminated Patients," 212.
108 One city got local police stations to "adopt" their neighborhood hospitals. Interview with author:
Physician/University Hospital Department of Emergency Medicine (20 September 2000). Some police departments have offered
to help hospitals with security, but are not guaranteeing such aid because they anticipate being overburdened with requirements
at the incident scene. Interviews with author: Director, Emergency Management Division, County Department of Public Safety
(19 September 2000); Police Lieutenant, Tactical Support Office (18 September 2000); Hazmat Coordinator/Instructor (8
September 2000); Battalion Fire Chief, Special Operations (25 May 2000); Paramedic (12 May 2000); Fire Sergeant (9 May
2000); Registered Nurse/Chief, EMS Division, State Emergency Management Specialist, Office of Emergency Management (9
May 2000); Department of Public Health (3 February 2000); Director of Hospital EMS and Disaster Medicine (19 April 1999);
EMS Superintendent-in-Chief (24 March 1999); Police Captain/Staff, Office of the Chief (9 March 1999); Registered
Nurse/Hospital Disaster Coordinator (4 February 1999). Other police departments have yet to see why they would need to offer
the hospitals security assistance during this type of a crisis. Interviews with author: Emergency Planner, Hospital Health
Maintenance Organization (15 August 2000); Deputy Director, Office of Emergency Management (26 May 2000); Emergency
Management Specialist, Office of Emergency Management (9 May 2000); Registered Nurse/Emergency Planner, Public Health
Department (7 April 2000); Fire Captain/Assistant Emergency Management Coordinator (5 January 2000).
236 Ataxia: The Chemical and Biological Terrorist Threat and the US Response
police made no commitment to help, some hospitals were making provisions to bag and tag patients' personal
effects, and, if time permitted, to conduct rudimentary patient interviews. Such information would also be
helpful for follow-up care, both physical and mental, once victims were released from the hospital.109
Ideally, hospitals would receive some warning to ready decontamination and triage teams.
Notification of the hospitals is always in a city's emergency operations plan, but during the press of disasters
and even drills, the front line often forgets to alert the hospitals.110 One city's hospitals left nothing to
chance, having installed a cost-effective early warning system, described in box 6.5. Once notified, hospital
administrators would enact mass casualty plans and set up whatever decontamination capability was
available.
If throngs of contaminated patients hit their doorsteps, painfully few hospitals in the country have
decontamination capabilities sufficient to handle the onrush; among them are George Washington University
Hospital in Washington, DC, and Parkland Hospital in Dallas, Texas.111 Figure 6.4 diagrams Parkland's
decontamination facility, which has pull-down curtains affixed to the ceiling of the ambulance bay. Weather
permitting, an exterior decontamination capacity is preferable to avoid compromising hospital premises.112
109 One hospital has developed a standard form to be filled out during registration to give to law and public health
officials to enable follow-up activities with these people after they are released from the hospital. Interview with author:
Emergency Management Specialist, Office of Emergency Management (9 May 2000). Also, on the importance of hospital
security and patient tracking: Emergency Planner, Hospital Health Maintenance Organization (15 August 2000); Physician,
Hospital Department of Emergency Medicine (24 March 2000); Physician/EMS Medical Director (13 November 1999); Project
Manager, Emergency Management Planning, Office of Emergency Management (27 July 1999); Physician, Hospital Division of
Emergency Medicine (31 May 1999).
110 Interviews with author: Director, Emergency Management Division, County Department of Public Safety (19
September 2000); Medical Toxicologist/Poison Control Center Director (13 June 2000); Physician, Hospital Division of
Emergency Medicine (31 May 2000); Emergency Management Specialist, Office of Emergency Management (9 May 2000);
Physician, Hospital Department of Emergency Medicine (23 March 1999); Physician/Associate Director, Hospital Department of
Emergency Medicine (9 March 1999); Registered Nurse/Hospital Disaster Coordinator (4 February 1999).
111 Interview with author: Physician, Hospital Division of Emergency Medicine (31 May 2000). Also, Anthony G.
Macintyre et al., "Weapons of Mass Destruction Events With Contaminated Casualties," 2429. A couple of hospitals reported
plans to install decontamination showers in their ambulance bays or at other entrances near their emergency departments, but
they are having difficulty obtaining the relatively modest funding needed for such construction. Interviews with author: Director,
Emergency Services Department (18 May 2000); Physician/Director of Hospital Disaster EMS (27 July 1999); Emergency
Planner (8 March 1999).
112 Outdoor facilities must still attend to the runoff of possibly contaminated fluids. Indoor decontamination facilities
need to incorporate special air handling precautions. Interview with author: Physician, Hospital Division of Emergency
Medicine (31 May 2000); Deputy Coordinator, Fire Emergency Preparedness and Disaster Services (3 February 2000);
Physician/Director of Hospital Disaster EMS (27 July 1999); Physician, Hospital Department of Emergency Medicine (23
March 1999).
Chapter 6 Metropolis, USA: Progress, Pitfalls in Front-line Readiness 237
Box 6.5: Ensuring Early Notice of Mass Casualty Events to the Hospitals
Concerned that communications might fail during a disaster, one city has equipped all of its
hospitals with emergency receivers as a failsafe to ensure that they get the word from the outset.
These receivers, connected to the fire department's paging system, will provide all hospitals with a
live announcement warning of mass and/or possibly contaminated casualties. Each hospital has three
receivers, situated in more than one location in the hospital to ensure that the live announcement is
not missed. The tone alert receiver broadcasts four types of messages: 1) mass casualty warning; 2)
termination of message; 3) nuclear, biological, or chemical event warning; and, 4) test message.1
NOTES
1. Interview with author: Emergency Management Specialist (9 May 2000). The newer model of the Emergency Alert
Receiver (EAR) is called the Informer. Federal Signal Corporation enhanced the receiver to decode and broadcast messages
at high volume, adding a battery back-up system. The Informer costs about $300 per unit. For more, see the company's
website at http://www.federalwarningsystems.com. Also, "EAS Receiver from Federal," Product Profile, 911 Magazine,
September/October 1997. Internet: http://www.9-1-1magazine.com/magazine/1997/0997/depts/products.html. Downloaded
15 September 2000. Other cities have put similar tone alert radios in hospital emergency departments. Interview with
author: Physician/University Hospital Department of Emergency Medicine (20 September 2000); Director, Emergency
Management Division, County Department of Public Safety (19 September 2000); Police Lieutenant, Tactical Support Office
(18 September 2000); Deputy Director, Office of Emergency Management (26 May 2000). One city does its hospital
notification via its poison control center. Interview with author: Director, County Emergency Management (21 September
2000).
Usually, the hospital plant, housekeeping, and services support staff, not doctors and nurses, were being
assigned decontamination chores. Ideally, enough staff on each shift would be trained for initial and relief
crews, and the evening, night, and weekend shifts, not just the daytime personnel, would be drilled.113 The
objective for a hospital decontamination capability is not to create luxury baths, but a snap capability to get
people undressed, hose them down, and put them in hospital gowns. Front-line veterans argued that this task
should not require maximum protective gear.114
113 For technical cases, such as an intubated patient, one hospital is relying on the staff of its rehabilitation center.
These individuals, who are accustomed to working with non-ambulatory patients, will be on-call twenty-four hours a day for
decontamination. Emergency Management Specialist, Office of Emergency Management (9 May 2000). Other individuals who
indicated that their hospitals that have trained support staff: Physician, Hospital Division of Emergency Medicine (31 May
2000); Associate Hospital Administrator/Registered Nurse (13 November 1999); Physician, Hospital Department of Emergency
Medicine (24 March 1999); Registered Nurse/Hospital Disaster Coordinator (4 February 1999). On training nurses as
decontamination teams: EMS Licensing Agent, State Department of Public Safety (27 January 2000). On the need to train others
outside of the emergency department: Fire/Rescue Instructor, former Director, Hospital Security (21 August 2000); Emergency
Planner, Hospital Health Maintenance Organization (15 August 2000).
114 Interviewees posited that level B or lower protective clothing should suffice under these circumstances, which runs
contradictory to OSHA's regulatory stance. Interviews with author: Fire EMS Statistician (30 August 2000); Fire/Rescue
Instructor, former Director, Hospital Security (21 August 2000); Medical Toxicologist/Poison Control Center Director (13 June
2000); Physician, Hospital Division of Emergency Medicine (31 May 2000); Battalion Fire Chief, Special Operations (25 May
2000); Battalion Fire Chief (15 November 1999); Physician/Director of Hospital Disaster EMS (27 July 1999); Emergency
Preparedness Director, Office of Emergency Services (9 February 1999).
238 Ataxia: The Chemical and Biological Terrorist Threat and the US Response
Several reasons explain why far too few US hospitals have beefed up their decontamination
capabilities. First, in the era of managed care service cutbacks, privately owned hospitals are extremely
reluctant to authorize capital improvements. Second, publicly funded hospitals are also on tight budgets,
barely able to keep their gurneys operational, as one physician put it. Third, health care facilities have
received only a trickle of the federal grant funds for terrorism preparedness.115 Finally, most hospital
administrators see no particular reason to focus on this problem, knowing that JCAHO and OSHA do not
dwell on decontamination capabilities. Moreover, many either have an "it-won't-happen-here" attitude or
naively believe, statistics to the contrary, that patients would arrive decontaminated.116
In the interim until hospitals establish a genuine decontamination capability, two basic strategies
were being employed to relieve the decontamination bottleneck at hospitals. Some cities allotted a portion
Figure 6.4: Diagram of Decontamination Facility at Parkland Hospital (Dallas
, Texas)
Drainage Grate
Gross Final Rinse Final Triage
Decontamination (Female) (Female)
(Female) EMERGENCY
TRIAGE DEPARTMENT
ENTRANCE
Gross Final Rinse Final Triage
Decontamination (Male) (Male)
(Male)
Hospital Personnel Control Zone
Curtained walls for privacy
Source: Kathy J. Rinnert, MD, MPH, "Weapons of Mass Destruction Preparedness: Parkland Health and Hospital System's Approach,"
presentation at the National Disaster Medical System Conference, 29 April 2000, Las Vegas, Nevada.
115 Interviews with author: General Manager, Emergency Department (22 September 2000); Director, Emergency
Management Division, County Department of Public Safety (19 September 2000); Police Lieutenant, Tactical Support Office (18
September 2000); Fire EMS Statistician (30 August 2000); Physician, Division of Disease Control, Public Health Department (8
August 2000); Commander, US Public Health Service (3 July 2000); Medical Toxicologist/Poison Control Center Director (13
June 2000); Physician, Hospital Division of Emergency Medicine (31 May 2000); MMRS Coordinator, Fire Department (9 May
2000); Registered Nurse/Chief, EMS Division, State Department of Public Health (3 February 2000); Associate Hospital
Administrator/Registered Nurse (13 November 1999); Physician, Director of Hospital Disaster EMS (27 July 1999); EMS
Superintendent-in-Chief (24 March 1999); Physician/Associate Director, Hospital Department of Emergency Medicine (9 March
1999); Registered Nurse/Hospital Disaster Coordinator (4 February 1999); Paramedic/Emergency Planner, Public Health
Department (4 February 1999).
116 Interviews with author: Fire Commander (19 April 1999); Emergency Preparedness Director, Office of Emergency
Services (9 February 1999); Registered Nurse/Hospital Disaster Coordinator (4 February 1999).
Chapter 6 Metropolis, USA: Progress, Pitfalls in Front-line Readiness 239
of the federal equipment grants to purchase showers, Tyvek suits, inflatable tents, wading pools to catch run-
off, and hoses for their hospitals.117 The fire departments in such cities were banking that with this
equipment the hospitals could stand on their own.118 The prevailing assumption, however, is that hospitals
would still be overrun, so some city emergency planners were trying to draft fire stations to aid the hospitals.
Some fire departments, asserting that their hands would be full at the incident scene and with routine
emergency calls, would commit only to pull decontamination trailers to the hospitals, unlock them, and help
hook up the hoses.119 With persuasion, other fire departments agreed to assign a fire company to each
hospital, providing equipment and staff for incoming patient decontamination.120 Some cities would activate
mutual aid agreements with neighboring communities for this task.121
Other Difficulties in Hospital Care
If past disaster experience proves true to form, the first people to reach hospitals would not be the
117 Interviews with author: Director, County Emergency Management (21 September 2000); Registered
Nurse/Emergency Planner, Public Health Department (7 April 2000); Deputy Coordinator, Fire Emergency Preparedness and
Disaster Services (3 February 2000); Lieutenant/Hazmat Commander (10 March 1999); Emergency Preparedness Director,
Office of Emergency Services (9 February 1999). Some cities took this step long before the domestic preparedness effort began.
One purchased the same decontamination kits that all of its fire engines carry for its six main hospitals. Interview with author:
Battalion Fire Chief (19 January 2000). Sometimes purchases were made without consulting the hospitas and provided only
some of the gear needed. Some fire departments are not offering to help with initial or refresher training for hospital staff.
Interviews with author: Registered Nurse/Chief, EMS Division, State Department of Public Health (3 February 2000); Fire
Captain/Assistant Emergency Management Coordinator (5 January 2000). In other areas, fire departments have helped hospitals
shop at local hardware stores, select inexpensive equipment, and train. Interviews with author: Police Lieutenant, Tactical
Support Office (18 September 2000); Fire EMS Statistician (30 August 2000); Emergency Planner, Hospital Health Maintenance
Organization (15 August 2000); Battalion Fire Chief, Special Operations (25 May 2000).
118 Interviews with author: Deputy Director, Office of Emergency Management (26 May 2000); District Fire Chief,
EMS Division (2 March 2000); Deputy Coordinator, Fire Emergency Preparedness and Disaster Services (3 February 2000).
119 Interviews with author: Registered Nurse/Emergency Planner, Public Health Department (7 April 2000); Associate
Hospital Administrator/Registered Nurse (13 November 1999); Fire Lieutenant and Fire Captain (5 February 1999); Registered
Nurse/Hospital Disaster Coordinator (4 February 1999). Other fire departments are just saying no. Interviews with author:
Director, Emergency Management Division, County Department of Public Safety (19 September 2000); Paramedic (12 May
2000).
120 One city got local fire stations to "adopt" their neighborhood hospitals. Interview with author: Physician/University
Hospital Department of Emergency Medicine (20 September 2000). Also on fire departments assigning companies to hospitals:
Director, Emergency Management Division, County Department of Public Safety (19 September 2000); Hazmat
Coordinator/Instructor (8 September 2000); Fire EMS Statistician (30 August 2000); Battalion Fire Chief (19 January 2000);
Director of Hospital EMS and Disaster Medicine (19 April 1999); EMS Superintendent-in-Chief (24 March 1999);
Lieutenant/Hazmat Commander (10 March 1999); Physician/Associate Director, Hospital Department of Emergency Medicine (9
March 1999).
121 One city was training more than thirty surrounding cities and towns in hazmat and decontamination skills.
Interviews with author: Assistant Director, Office of Emergency Management (23 March 1999); Deputy Fire Chief (23 March
1999); Police Lieutenant (23 March 1999). Also on plans to activate mutual aid agreements for this purpose: Fire EMS
Statistician (30 August 2000); Lieutenant/Hazmat Commander (10 March 1999).
240 Ataxia: The Chemical and Biological Terrorist Threat and the US Response
more seriously wounded.122 Frightened, but mobile victims often depart the scene before rescue crews can
attend to them, finding their way to hospitals by any means available, even on foot. In the case of a chemical
terrorist attack, intermingled with these not too seriously injured patients would be those who hear news
reports and worry that a toxic plume might have come their way. Epidemic hysteria is a fear of having been
exposed to toxic substances that is so palpable that people exhibit real physical symptoms (e.g., fainting,
sweating, nausea).123 After the subway gas attack in Tokyo, some 5,510 went to hospitals and clinics, but
roughly 85 percent were psychogenic patients.124 Another wave of epidemic hysteria took place on 26
August 1993, after a plume of gaseous sulfur trioxide and sulfuric acid was released from the General
Chemical plant in Richmond, California. According to EMS records, twenty-two people with exposure
symptoms were taken to hospitals, with no fatalities. Over the next ten days, however, fifteen hospitals and
two clinics saw twenty-two thousand people complaining of exposure symptoms.125
In short, hospitals would face a sea of humanity after a chemical terrorist attack, with everyone
demanding help. The hospital's priority would be to get medical treatment to those genuinely suffering the
effects of poison gas exposure. Consequently, hospitals planned to page off-duty staff and were adjusting
triage practices to cope with large numbers of contaminated and the worried well patients.126 Experts suggest
separating the worried well from the genuinely injured so that their behavior would not be reinforced by
122 As noted in chapter 3, such was the case after the Tokyo subway attack.
123 Examples of mass psychogenic illness abound, such as the case in an East Texas university town on 15 June 1983.
Parathion leaked from a greenhouse, sending over 115 to the hospital, where doctors found that ninety-nine of the 119 patients
showed no clinical evidence of organophosphate poisoning. The worried well saw the behavior of individuals who were exposed
to the parathion, were told by others that the gas was dangerous, and were encouraged to go to the hospital. Many, although not
actually ill, did. Psychogenic illness is a phenomenon whereby "large groups of people in situations accompanied by stress or
conflict are much more susceptible to contagion" and consequently begin to imitate the symptoms of others. Louis A. Gamino,
Gary R. Elkins, Kenneth U. Hackney, "Emergency Management of Mass Psychogenic Illness," Psychosomatics 30, no. 4 (Fall
1989): 4478. For another case of mass psychogenic illness, see, Timothy F. Jones et al., "Mass Psychogenic Illness Attributed
to Toxic Exposure at a High School," New England Journal of Medicine 342, no. 2 (13 January 2000): 96100.
124 Of the 5,510, seventeen were deemed critical, thirty-seven severe, and 984 moderately ill, meaning they experienced
slight problems. For additional discussion, see chapter 3.
125 A safety valve ruptured while offloading a chemical from a railroad tank car, causing the release. Forty minutes
after being notified of the incident, emergency response officials activated the alert system that instructs citizens to stay indoors
and to shelter-in-place, for their own safety. Just over ninety minutes into the emergency, callers could no longer get through to
an overloaded 911 center. "Emergency Medical Response: General Chemical Incident, August 26, 1993," Summary Report
(Contra Costa, Calif.: EMS Agency, Contra Costa Health Services Department, n.d.), 12.
126 Interviews with author: Physician, Hospital Division of Emergency Medicine (31 May 2000); Project Manager,
Emergency Management Planning, Office of Emergency Management (27 July 1999); Physician, Hospital Department of
Emergency Medicine (24 March 1999); Emergency Preparedness Director, Office of Emergency Services (9 February 1999);
Registered Nurse/Hospital Disaster Coordinator (4 February 1999). See also, Anthony G. Macintyre et al., "Weapons of Mass
Destruction Events With Contaminated Casualties," 2429.
Chapter 6 Metropolis, USA: Progress, Pitfalls in Front-line Readiness 241
seeing those with actual symptoms. Gradually, with comfort and positive suggestion, the symptoms of
psychogenic patients would abate.127
Once patients get inside the door, hospital personnel expect a host of other obstacles, beginning with
the novelty of treating chemical casualties and continuing to critical shortages in beds and supplies.
Toxicology is the only medical specialty that specifically trains physicians in the proper care and treatment
of people who have ingested or otherwise come in contact with poisonous substances. In the entire country,
there are fewer than 250 medical toxicologists. These specialists are likely to be affiliated with one of the
seventy registered US poison control centers.128 Otherwise, the civilian medical ranks are terribly thin in
chemical casualty expertise. Physicians in emergency medicine have a required training rotation in
toxicology,129 but emergency departments see far more broken bones, gunshot wounds, and other traumas
than patients who have tangled with toxic chemicals. In cities participating in the preparedness training
program, emergency department personnel may have received a refresher course in chemical casualty care,
but in all likelihood, the remainder of the medical community (e.g., internists, surgeons, family practitioners)
is hardly braced for this type of injury. Much the same can be said of the nursing staffs. Consequently, there
is concern that emergency departments, which normally send patients on to other hospital departments for
more advanced, specialized care, would in these circumstances be passing patients off to a lesser standard
of care.130
The first thing that physicians and nurses reach for when confronted with a patient with unfamiliar
signs and symptoms is a treatment protocol. A few hospitals and metropolitan hospital committees have
127 The worried well can be calmed with encouraging words noting that "the effects of this chemical are temporary, not
serious" and that an individual "should be feeling better soon." Gamino, Elkins, Hackney, "Emergency Management of Mass
Psychogenic Illness," 448.
128 Interview with author: Medical Toxicologist/Poison Control Center Director (13 June 2000). Medical toxicology
was recognized as a sub-specialty in 1993. Currently, there are 240 practicing medical toxicologists in the country. The nearest
medical toxicologist can be located by state at the American College of Medical Toxicology website at: http://www.acmt.net.
Interview with author: Heather Miller, Executive Director, American College of Medical Toxicology (21 September 2000).
Numbers of poison control centers dwindled in the last few decades, but the 1999 Poison Center Enhancement and Awareness
Act was passed in February 2000 to help stabilize funding for the centers, connect the centers to expertise nationwide, and
publicize a toll-free information number. For more information, see the American Association of Poison Control Centers'
website at: http://www.aapcc.org. Downloaded on 21 September 2000.
129 In a 1998 survey of seventy-six individuals in various positions in emergency medicine residency programs, 84
percent reported that their program included formal training in hazardous materials. Just over 51 percent of the instruction was
via lecture and didactic exercises, 12.8 percent was through specific rotations or field exercises, and 7.7 percent through training
courses. Nicki Pesik, Mark Keim, Tomoko Rie Sampson, "Emergency Medicine Residency Program Training for Bioterrorism,"
Annals of Emergency Medicine 34, no. 2 (August 1999): 175.
130 Interviews with author: Medical Toxicologist/Poison Control Center Director (13 June 2000); Physician, Hospital
Division of Emergency Medicine (31 May 2000); Director of Hospital EMS and Disaster Medicine (19 April 1999). Also on the
lack of chemical casualty instruction in nursing and medical schools: Registered Nurse/Emergency Planner, Public Health
Department (7 April 2000); Registered Nurse/Chief, EMS Division, State Department of Public Health (3 February 2000);
Associate Hospital Administrator/Registered Nurse (13 November 1999).
242 Ataxia: The Chemical and Biological Terrorist Threat and the US Response
drafted guidelines to manage chemical casualties and shared them locally.131 Hospitals without a medical
toxicologist on staff would probably contact the nearest poison control center, where the staff may or may
not be comfortable with its level of knowledge about this type of casualty. Otherwise, physicians might
scour the military medical literature for data on patient care.132 As noted, an expert panel had begun work
on civilian chemical protocols,133 without which hospitals would be hard pressed to cope with chemical
casualties.
An additional hurdle confronting disaster planners is that US hospitals are filled to near capacity on
a daily basis. Health care officials in several cities explained that bed shortages routinely compel hospitals
to go on "bypass" during the influenza season, requesting EMS crews to take patients elsewhere. Repeatedly,
medical professionals estimated that at any given time there would be at most a dozen, probably half a dozen
intensive care unit (ICU) beds available in the entire city. Burn beds and ventilators, which would be critical
for the recovery of blister and nerve agent casualties, respectively, would be in just as short supply.134 One
state put its hospital association on tap to canvas the region for respirators after a chemical terrorist attack,
and police aircraft were slated to retrieve those not in use.135
Health care officials anticipated having considerable difficulty figuring out where bed space was
available in their metropolitan area. Securing information about the status of hospitals is time consuming
even under ordinary circumstances. One public health department annually pulses city hospitals to ascertain
the number of available medical, burn, and ICU beds. This all-shift survey reveals that it regularly takes
131 Interviews with author: Medical Toxicologist/Poison Control Center Director (13 June 2000); Physician, Hospital
Division of Emergency Medicine (31 May 2000); Emergency Management Specialist, Office of Emergency Management (9 May
2000).
132 Interview with author: Toxicologist (13 June 2000). Data can be found mostly in military medical literature,
volumes, unfortunately, not likely to be in most doctors' libraries. See, for example, T.C. Marrs, R.L. Maynard, and F.R. Sidell,
eds., Chemical Warfare Agents: Toxicology and Treatment (Chichester, United Kingdom: Wiley & Sons, 1996); Sidell, Takafuji,
and Franz, eds., Medical Aspects of Chemical and Biological Warfare.
133 See footnote 93.
134 Several interviewees reported that ambulances sat in their emergency department bays for one or more hours during
flu season, with EMS crews attending to their patients until hospital beds became available. Some reported having to transfer
non-critical patients to other cities. Interviews with author: Physician/University Hospital Department of Emergency Medicine
(20 September 2000); Physician/Director of Health, Public Health Department (20 September 2000); Fire EMS Statistician (30
August 2000); former State Epidemiologist (18 August 2000); Emergency Planner, Hospital Health Maintenance Organization
(15 August 2000); Physician, Division of Disease Control, Public Health Department (8 August 2000); Medical
Toxicologist/Poison Control Center Director (13 June 2000); Physician, Hospital Division of Emergency Medicine (31 May
2000); Paramedic (12 May 2000); Registered Nurse/Chief, EMS Division, State Department of Public Health (3 February 2000);
Physician/EMS Medical Director (13 November 1999); Project Manager, Emergency Management Planning, Office of
Emergency Management (27 July 1999); EMS Superintendent-in-Chief (24 March 1999); Physician, Hospital Department of
Emergency Medicine (24 March 1999). Also, Michael T. Osterholm and John Schwartz, Living Terrors (New York: Delacorte
Press), 1334.
135 Interview with author: Fire EMS Statistician (30 August 2000).
Chapter 6 Metropolis, USA: Progress, Pitfalls in Front-line Readiness 243
hospitals at least an hour to provide their status, even on the night shift, which is presumably quieter than
the others.136 Hospitals would therefore have to juggle furiously to find open bed space to relieve the patient
burden at some hospitals. This endeavor would be complicated by overloaded EMS emergency frequencies
and jammed telephone circuits that would impede voice, facsimile, and Internet communications. Some
cities had instituted a rudimentary computerized tracking system for hospital status, working off data
provided by EMS and emergency department personnel.137 In a crisis that causes a rapid crescendo of
patients, this tool may not be of much utility because EMS and emergency department personnel would
rightfully put patient care above record keeping.
Finally, another time-critical issue that hospitals must deal with would be the availability of antidotes
for poisonings. Cities designated for MMRS teams received grant funds to purchase chemical antidotes.
Given the limited shelf-lives and utility of these drugs, local officials expressed concern that the cities might
not restock these supplies. If restocking does not occur, then the MMRS cities would be in the same situation
as all other US cities, with hospitals unlikely to have minimal, much less large supplies of needed chemical
antidote medicines. One city surveyed its hospitals prior to a major international gathering and found enough
atropine among them to treat sixty nerve agent casualties.138
Several surveys since the mid-1980s have found hospital emergency departments to be woefully short
on poison antidotes, and hospitals are not required to have specified amounts of these drugs available. An
August 2000 study recommended that hospitals receiving emergency patients have sixteen antidotes in their
pharmacies at all times, but the quantities specified were for regular circumstances, not unusual situations
like terrorist attacks.139 In short, a nationwide antidote stocking standard for routine emergencies is still in
the making, and policies for more extraordinary circumstances have yet to take shape. In the interim, some
cities were purchasing powdered atropine, which has an indefinite shelf life and is inexpensive, for
hospitals.140 Other cities said they would procure atropine from veterinary clinics. One city's contingency
136 The night shift response time has averaged one-and-a half hours. Interview with author: Registered Nurse/Chief,
EMS Division, State Department of Public Health (3 February 2000).
137 These tracking systems are described more thoroughly in the discussion on bioterrorism preparedness.
138 Interview with author: Physician/Associate Director, Hospital Department of Emergency Medicine (9 March 1999).
139 On the recommended list of antidotes are atropine, 2-PAM, and cyanide kits. JCAHO does not stipulate quantities
of antidotes that hospitals must maintain, despite strong support of hospital pharmacy directors for such a universal policy.
Richard C. Dart et al., "Combined Evidence-Based Literature Analysis and Consensus Guidelines for Stocking of Emergency
Antidotes in the United States," Annals of Emergency Medicine 36, no. 2 (August 2000): 12632. On the difficulty of
establishing local antidote stockpiles, see Brennan, Waeckerle, Sharp, and Lillibridge, "Chemical Warfare Agents: Emergency
Medical and Emergency Public Health Issues," 197.
140 All hospitals have atropine on cardiac crash carts in quantities that may allow them to squeeze by until powdered
atropine is reconstituted. Hospitals usually do not have supplies of 2-PAM on hand. Veterinary clinics also have supplies of
atropine. Interviews with author: Physician/University Hospital Department of Emergency Medicine (20 September 2000);
Medical Toxicologist/Poison Control Center Director (13 June 2000); Physician, Hospital Division of Emergency Medicine (31
244 Ataxia: The Chemical and Biological Terrorist Threat and the US Response
plan included arrangements with area military posts for around-the-clock access to their caches of Mark 1s.141
Since the primary scenario driving much of the planning was a nerve agent attack, not much headway was
made in addressing antidote shortages for other chemical agents.
LOCAL BLUEPRINTS FOR RESPONDING TO A
BIOLOGICAL TERRORIST ATTACK
Ask medical health care providers, city emergency planners, public health officials, and first
responders what their challenges would be after a terrorist attack with biological agents and the answer
begins invariably with a question: How would they know such an attack has taken place? Unlike a chemical
terrorist attack, which announces itself instantly with choking, faltering victims, the symptoms of many
biological warfare agents do not materialize for days. Terrorists eager for maximum publicity could
announce their attack, in which case authorities would swing into action with epidemiological and criminal
investigations, possible medical prophylaxis of local citizens, and other measures. Because one advantage
of using a biological agent in the first place is that an attack can be executed anonymously and give terrorists
time to escape, prevailing wisdom holds that terrorists would release an agent covertly, sit back, and watch
the havoc gradually unfurl.
Thus, the first concern that weighs on the minds of medical and emergency response personnel is
that they would probably not know that a disaster was burgeoning in their midst until after a great deal of
damage had already been done. Local authorities next list worries about the ability to keep hospitals open
under the intense pressure that such an attack would generate, starting with medical manpower shortages that
would materialize all too quickly, especially among the nursing ranks. Without missing a beat, they note that
hospitals would rapidly run out of beds and drugs. Then, they move on to the logistics of attempting to treat
large populations, puzzling over how to amass sufficient personnel, equipment, and medicines within a
crunched time period. Finally, they shudder at the thought of trying to quarantine large numbers of people
if a contagious disease were involved.
More so than a chemical terrorist incident, which can be expected to overtax emergency response
services for a finite period of time, the possibility a bioterrorist attack causes trepidation in the health care
community. Some diseases would erupt over a period of weeks, creating wave after wave of illness. Perhaps
it is not surprising, then, that front-line responders and health care providers did not rate themselves as highly
on bioterrorism preparedness as they did on chemical terrorism preparedness. As before, the ratings were
May 2000); Physician/Hospital Department of Emergency Medicine (15 June 1999); Physician/Associate Director, Hospital
Department of Emergency Medicine (9 March 1999). One hospital system is buying a limited amount of atropine in vials, which
can be used while the powdered atropine is being reconstituted. Interview with author: Emergency Planner, Hospital Health
Maintenance Organization (15 August 2000).
141 Interview with author: EMS Specialist/Paramedic (12 May 2000).
Chapter 6 Metropolis, USA: Progress, Pitfalls in Front-line Readiness 245
subjective and the proposed scale was from 1 to 10, with one being the lowest. For thirteen local officials,
a rating of 1 prior to the federal planning, training, and equipment programs described in chapter 5 was
simply not low enough. Ten backed their "before" assessments to zero, while three locals went into the
negative integers, with the worst rating being negative ten. Given that the cities were literally working from
ground zero, the self-assessments in figure 6.5 show that these programs have begun to make a positive
difference in recipient cities. The peaks in appraisals before assistance fall between zero and two, while the
crests in the post-training phase run between two and five. The average score before the federal aid programs
was 1.7, rising to 4.1 afterward. The mean improvement was 2.5. These ratings also indicate just how far
cities receiving federal aid believe they have to go before they could truly handle a major infectious disease
outbreak. In reality, said one local official, no city in the country was ready to cope with 10 percent or more
of its population simultaneously falling deathly ill. Just getting the plans, supplies, and manpower lined up
to try to keep a lethal infectious disease from spreading is a gargantuan challenge. "Other than that," said
this official, (who gave a "before" rating of two and an after rating of five), "it would really be about letting
people die with dignity."142
Factors Retarding the Ability to Detect a Covert Bioterrorist Attack
The United States may be home to the most advanced and heralded medical care in the world, but
that does not change the fact that the components of the nation's disease surveillance system are ill-prepared
to pick up the signs of a covert bioterrorist attack. This system has deteriorated since its 1950s heyday as
modern medicine conquered one disease after another.143 In each state, physicians, dentists, and other
personnel are required by law to notify public health authorities of the occurrence of certain diseases, but
doctors have trouble diagnosing diseases from generic clinical symptoms. Therefore, the backbone of the
nation's disease surveillance system is 158,000 state and local public health and private laboratories, which
by far do most of their reporting after identifying pathogens via analysis of cultures. Reportable diseases
142 Interview with author: Director, City Emergency Services Department (18 May 2000).
143 This system was created during the onset of the Cold War, largely due to significant concerns about the use of
biological and chemical agents. Discussion of the decline of the disease surveillance system and its ramifications can be found in
Institute of Medicine, Chemical and Biological Terrorism: Research and Development to Improve Civilian Medical Response,
National Research Council (Washington, DC:, National Academy Press, 1999); General Accounting Office, Emerging Infectious
Diseases: Consensus on Needed Laboratory Capacity Could Strengthen Surveillance, GAO-HEHS-99-26 (Washington, DC: US
General Accounting Office, 5 February 1999). Also, interviews with author: Division Chief, State Disaster Medical Services
Division (15 February 2000); Toxicologist (9 March 1999).
246 Ataxia: The Chemical and Biological Terrorist Threat and the US Response
Figure 6.5: Local Officials Assess Their Preparedness for a Large-Scale Biological Terrorist Event*
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1 8
1 6
s 14
nseo 12
spe R 10
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um 6
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*Not all local officials interviewed for this report were asked to rate themselves and some who were asked declined to do so. The survey
includes the appraisals of responders from twenty-two cities, although interviews were conducted in over thirty cities. Some responders
were from cities that at the time of the interview had received only the Domestic Preparedness Program training, and others were from
cities also enrolled in the Metropolitan Medical Response System program. Some cities had received equipment grants from the Justice
Department, others had not.
Sources: Interviews with author: General Manager, Emergency Department (22 September 2000); EMS Chief, Emergency Services Department (21
September 2000); Director, County Emergency Management (21 September 2000); Physician/University Hospital Department of Emergency Medicine (20
September 2000). Physician, Director of Health, Public Health Department (20 September 2000); Director, Emergency Management Division, County
Department of Public Safety (19 September 2000); Director, Office of Emergency Preparedness (19 September 2000); Police Lieutenant, Tactical Support
Office (18 September 2000); Hazmat Coordinator/Instructor (8 September 2000); Fire EMS statistician (30 August 2000); Emergency Planner, Hospital
Health Maintenance Organization (15 August 2000); Police Lieutenant (8 July 2000); Medical Toxicologist/Poison Control Center Director (13 June 2000);
Physician, Hospital Division of Emergency Medicine (31 May 2000); Deputy Director, Office of Emergency Management (26 May 2000); Battalion Fire
Chief, Special Operations (25 May 2000); Director, Emergency Services Department (18 May 2000); Emergency Management Specialist, Office of
Emergency Management (9 May 2000); Police Sergeant (9 May 2000); MMRS Coordinator, Fire Department (9 May 2000); Registered Nurse/Emergency
Planner, Public Health Department (7 April 2000); Registered Nurse/Chief, EMS Division, State Department of Public Health (3 February 2000); Deputy
Coordinator, Fire Emergency Preparedness and Disaster Services (3 February 2000); Detective/Bomb Squad (19 January 2000); Project Manager,
Emergency Management Planning (27 July 1999); Director of Hospital EMS and Disaster Medicine (19 April 1999); Toxicologist, Poison Control Center (9
March 1999); Emergency Planner, Office of Emergency Management (8 March 1999); District Fire Chief, EMS Division (2 March 2000); Police
Captain/Firing Range Director (5 February 1999); Emergency Response Planner, Office of Emergency Management (5 February 1999); Captain/Assistant
Emergency Management Coordinator (5 January 2000); Battalion Fire Chief (17 November 1999); Battalion Fire Chief/Emergency Services Administrator
(15 November 1999); Battalion Fire Chief (15 November 1999); Associate Hospital Administrator/Registered Nurse (13 November 1999); EMS
Superintendent-in-Chief (24 March 1999); Physician, Hospital Department of Emergency Medicine (24 March 1999); Assistant Director, Office of
Emergency Management (23 March 1999); Deputy Fire Chief (23 March 1999); Lieutenant/Hazmat Commander (10 March 1999); Physician/Associate
Director, Hospital Department of Emergency Medicine (9 March 1999); Paramedic Operations Supervisor (9 March 1999); Fire Captain, HazMat Unit (9
February 1999); Emergency Preparedness Director, Office of Emergency Services (9 February 1999); Battalion Fire Chief (9 February 1999); Fire Battalion
Chief/Hazmat Specialist (8 February 1999); Police Lieutenant (8 February 1999); Battalion Fire Chief/EMS Supervisor (8 February 1999); Police Captain,
Special Operations Division (8 February 1999); Special Projects Program Manager, Department of Public Health (5 February 1999); Fire Lieutenant (5
February 1999); Paramedic/Emergency Planner, Public Health Department (4 February 1999); Director, Office of Emergency Services (4 February 1999)
Registered Nurse/Hospital Disaster Coordinator (4 February 1999).
Chapter 6 Metropolis, USA: Progress, Pitfalls in Front-line Readiness 247
differ from state to state, and nationwide some fifty to sixty public and private infectious disease surveillance
systems are in operation. Every week, however, the Centers for Disease Control and Prevention (CDC)
collects electronic data from states on sixty "nationally notifiable" diseases, including most of the diseases
weaponized for warfare purposes. State participation in this system is voluntary. According to a 1997
survey, 87 percent of US states incorporated at least 80 percent of the nationally notifiable diseases at that
time in their own reporting systems.144
A key weakness in the disease surveillance system is a reporting time lag that could be significant
if a lethal and/or communicable disease were involved. For instance, some state regulations allow health care
providers ten days from the point of detection to report a contagious disease case to the state
epidemiologist.145 Also hindering the quickness of disease reporting are cutbacks in laboratory staffing and
training, as well as antiquated computer and communications capabilities.146 Furthermore, disease reporting
regulations are not well policed, and the problem of under-reporting is so chronic that only 20 percent of the
cases of some diseases may be notified. The reports may not accurately reflect the extent of illness among
the population because those with milder symptoms may not see their physicians. Finally, doctors define
cases differently, which translates into additional reporting inaccuracy.147 In sum, this system is not geared
to work rapidly, which bodes poorly for detection of a highly contagious disease outbreak in time to prevent
a pandemic.
The difficulty of detecting an act of bioterrorism is compounded by the fact that the first signs and
symptoms of many biowarfare diseases are nonspecific. In several instances, these early symptoms are
characteristic of influenza, so some unwary victims would ignore their discomfort or tough it out at home,
taking over-the-counter medications. Others would see their regular physicians and in acute cases some
144 The CDC's National Center for Infectious Diseases is the focal point of infectious disease surveillance activities.
Additional layers of the national surveillance system include weekly data that state laboratories send the CDC on bacterial and
viral isolates. Depending upon the jurisdiction, hospitals and laboratories may also be obligated to make disease notifications.
Normally, the hospital channels its report to the local health department, which may take action on the case(s) before or as the
report is sent on to the state health department. Vital statistics (e.g., births, deaths) are kept through the National Health
Interview Survey, and national registries are also maintained for cancer and other illnesses. General Accounting Office,
Consensus on Needed Laboratory Capacity Could Strengthen Surveillance, 510. Also, Scott F. Wetterhall, "Surveillance
Systems," in Proceedings of the Seminar of Responding to the Consequences of Chemical and Biological Terrorism, pages 1-
1045. The list of nationally notifiable diseases can be found online at http://www.cdc.gov/epo/dphsi/infdis.htm. This list does
not include smallpox or Marburg, which the USSR is known to have weaponized. Nor does this list include Ebola, which Soviet
scientists also may have weaponized. Briefly, see chapter 2. More in depth, see Ken Alibek with Steve Handelman, Biohazard
(New York: Random House, 1999). The CDC publishes the compiled information online in the Morbidity and Mortality Weekly
Review.
145 Interviews with author: Emergency Management Specialist, Office of Emergency Management (9 May 2000);
Emergency Preparedness Director, Office of Emergency Services (9 February 1999).
146 General Accounting Office, Consensus on Needed Laboratory Capacity Could Strengthen Surveillance, 126.
147 Wetterhall, "Surveillance Systems," page 1-105.
248 Ataxia: The Chemical and Biological Terrorist Threat and the US Response
would go to emergency departments. Particularly, if terrorists stage an attack during winter, medical staffs
would not necessarily think that anything was out of the ordinary. The possibility that biowarfare agents
would be deliberately released is not on the index of suspicion of most triage nurses, nor are doctors trained
to consider this when making a differential diagnosis. Diseases like anthrax and Q fever crop up in the
United States so infrequently that medical and nursing schools only nominally address such illnesses in their
general curricula, leaving the preponderance of US physicians with only a smattering of instruction in the
symptomology and care of patients with infectious diseases.148
In all likelihood, physicians would send mildly ill patients home without ordering any diagnostic
tests, instructing them to drink plenty of fluids, take over-the-counter pain relief medications, and return if
their health does not improve. As a tide of patients comes back feeling worse, doctors would probably
consult with each other and start pulling cultures, such as throat swabs, stool and blood samples, and the like.
While a particularly alert triage nurse or physician may notice that the influx of patients came from the same
geographic area or attended the same event, in all likelihood harried doctors would move on to other patients,
admitting the severely ill to the ICU or other medical wards. There, they would be attended by physicians
who, with the exception of infectious disease specialists, are even less likely than their emergency
department colleagues to recognize the symptoms that manifest from exposure to biological agents. In short,
the medical community may not zero in on the reason people are falling ill until days or even weeks later,
when laboratory results are available.149
When a sample reaches the laboratory, things may come to a grinding halt for several reasons. First,
nature does not always cooperate. Microbes that grow rapaciously in the lungs or intestines can be fractious
148 "None of this is being taught in medical school, and none of this is being taught in classes on the management of
public health." Interview with author: Physician, Department of Public Health (23 May 1999). Also on this point: Medical
Toxicologist/Poison Control Center Director (13 June 2000); Physician, Hospital Division of Emergency Medicine (31 May
2000); Physician (29 May 2000); Registered Nurse/Emergency Planner, Public Health Department (7 April 2000); Registered
Nurse/Chief, EMS Division, State Department of Public Health (3 February 2000); Associate Hospital Administrator/Registered
Nurse (13 November 1999); Physician, Department of Public Health (23 May 1999); Director of Hospital EMS and Disaster
Medicine (19 April 1999).
149 Taking cultures when patients first come in might allow physicians to make a faster diagnosis, but these tests are
expensive, paperwork intensive, and time consuming. Doctors order cultures for suspected bacterial infections, but usually not
for suspected viral infections. During influenza outbreaks in more than one city, hospital physicians reported seeing dozens of
patients daily, but only culturing or admitting the most sickly among them. Interviews with author: Physician/Director of Health,
Public Health Department (20 September 2000); Physician (29 May 2000); Physician, Hospital Division of Emergency Medicine
(31 May 2000); Registered Nurse/Chief, EMS Division, State Department of Public Health (3 February 2000); Associate
Hospital Administrator/Registered Nurse (13 November 1999); Project Manager, Emergency Management Planning (27 July
1999); Physician/Associate Director, Hospital Department of Emergency Medicine (9 March 1999). See also, John G. Bartlett,
"Applying Lessons Learned from Anthrax Case History to Other Scenarios," Emerging Infectious Diseases 5, no. 4 (July/August
1999): 561.
Chapter 6 Metropolis, USA: Progress, Pitfalls in Front-line Readiness 249
in a petri dish, refusing to grow in solution after solution.150 Generally speaking, viral cultures are harder
to grow than bacterial cultures. Second, microbiologists have an even harder time growing cultures when
samples have not been taken with precision and properly prepared and stored. Third, microbiologists run
a series of time-consuming tests for ordinary diseases before they start testing for more exotic ones. When
laboratory technicians get an unexpected result like anthrax, they are likely to consider it a fluke, an error
caused by improper handling of the culture, and therefore disregard the result. Under their microscopes may
be a disease that microbiologists have only seen in textbooks. Therefore, the technician is likely to restart
the test, perhaps requesting that the sample be redrawn. At some point, a hospital laboratory technician
would put a difficult culture into a stack of "unknowns," awaiting the scrutiny of a pathologist, who may or
may not begin to decipher the microscopic puzzle, requesting more targeted diagnostic assays such as those
shown in table 6.2. Finally, some technicians, including those in private laboratories, may be unfamiliar with
how to plate and test for certain biowarfare agents. A special medium, for instance, has to be used to test
for anthrax.151 Late in 2000, the American Society of Microbiologists and the CDC were scheduled to release
guidelines for the hospital and private laboratory communities to improve their awareness and capabilities
for handling unusual cultures.152
For quite some time, relatively few laboratories outside of the CDC and the US Army Medical
Research Institute of Infectious Diseases even had the biosafety capacity to work with highly contagious and
lethal diseases.153 In 1999, the CDC began a program to rejuvenate state laboratory capabilities, which is
explained and mapped in chapter 4, but the vast majority of hospital, public health, and private laboratory
technicians have no reason to be particularly attuned to the possibility of a bioterrorist attack because they
150 For example, weeks passed as scientists tried various solutions and tactics attempting to get Legionnaire's disease to
grow in the laboratory. The finicky Legionella bacterium required a growth medium containing the amino acid cysteine,
vitamins, iron, and other minerals. See especially pages 174191 in Laurie Garrett, The Coming Plague: Newly Emerging
Diseases in A World Out of Balance (New York: Farrar, Straus and Giroux, 1994).
151 Prior to the laboratory, cultures pass through the hands of many individuals-from clinicians to delivery service
personnel-who are not necessarily trained in the appropriate procedures for taking, preparing, and storing cultures. Samples
can be easily adulterated by exposure to other elements or high temperatures. Interviews with author: Physician, Hospital
Division of Emergency Medicine (31 May 2000); Physician (29 May 2000); Registered Nurse/Chief, EMS Division, State
Department of Public Health (3 February 2000); Physician, Hospital Department of Emergency Medicine (24 March 1999). See
also, Bartlett, "Applying Lessons Learned from Anthrax Case History to Other Scenarios," 561.
152 The guidelines, which should be promulgated by the end of 2000, are an abbreviated version of the gold standard
protocols employed in the CDC's strengthened laboratory network. They emphasize the need to recognize unusual samples and
package them properly for more definitive analysis in one of the CDC's network laboratories. Interview with author: Senior
CDC official (29 August 2000).
153 The newest of the nation's four Biosafety Level 4 laboratories opened in San Antonio, Texas in August 2000. The
other three are located at the CDC in Atlanta, Georgia, the US Army Medical Research Institute for Infectious Diseases, in Ft.
Detrick, Maryland, and the National Institutes of Health in Washington, DC. Jeannie Kever, "Bringing a Hot Lab to Life," The
Houston Chronicle (magazine insert), 27 August 2000, 6.
250 Ataxia: The Chemical and Biological Terrorist Threat and the US Response
Table 6.2: Diagnostic Samples, Assays, and Isolation Precautions for Biological Warfare Agents
Agent Diagnostic Sample Diagnostic Assay Patient Isolation
(Biosafety Level) Precautions
Anthrax Blood (Level 2) Gram stain Standard precautions
Antigen-ELISA
Serology: ELISA
Brucellosis Blood, bone marrow, and Serology: agglutination Standard precautions
acute convalescent sera Culture
(Level 3) Contact isolation if
draining lesions present
Plague Blood, sputum, lymph node Gram or Wright-Giemsa Stain Pneumonic: droplet
aspirate (Level 2/3) Antigen-ELISA precautions until patient
Culture Serology: treated for 3 days
ELISA, immunofluorescence
assay
Q Fever Serum (Level 2/3) Serology: ELISA, Standard precautions
immunofluorescence assay
Tularemia Blood, sputum, serum, Culture Standard precautions
electron microscopy of Serology: agglutination
tissue (Level 2/3)
Smallpox Pharyngeal swab, scab ELISA, polymerase chain Airborne precautions
material (Level 4) reaction, virus isolation
Viral Serum Viral isolation Standard precautions
encephalatides (Level 2 for Eastern equine Serology: ELISA or (mosquito control)
and Western equine hemogglutination inhibition
encephalitis; Level 3 for
Venezuelan equine
encephalitis)
Viral Serum, blood (Level 4 for Virus isolation Contact precautions
hemorrhagic most viral hemorrhagic Antigen-ELISA
fevers fevers; Level 3 for Rift Reverse transcriptase Consider additional
Valley fever, yellow fever, polymerase chain reaction precautions if massive
and Korean hemorrhagic Serology: antibody ELISA hemorrhage
fever)
Botulinum Nasal swab (Level 2) Antigen-ELISA, mouse neutral Standard precautions
Staphylococcal Nasal swab, serum, urine Antigen-ELISA Standard precautions
enterotoxin b (Level 2) Serology: antibody-ELISA
ELISA: enzyme-linked immunosorbent assay
Source: David R. Franz et al., "Clinical Recognition and Management of Patients Exposed to Biological Warfare
Agents," Journal of the American Medical Association 278, no. 5 (6 August 1997): 4001.
Chapter 6 Metropolis, USA: Progress, Pitfalls in Front-line Readiness 251
have not been targeted for awareness or other technical training.154 Therefore, they would refer a difficult,
unknown culture up the laboratory chain, with the hospital or private laboratory sending the sample to the
local public health lab, which would pass the culture on to its state counterpart, which may in turn bump it
to the CDC or the Army's experts. With delays for the re-tests, several days, sometimes weeks, may pass
before laboratories unravel the mystery.155
While waiting for laboratory results, doctors may not piece together the pattern of disease occurring
in their community, even when the clinical symptoms are pronounced. A physician in Pennsylvania's
Allegheny County tested how alert his on-duty colleagues were to the stigmata of the smallpox, which has
not been seen in the United States for decades. Of seventeen physicians quizzed, only one of the two
infectious disease specialists who participated correctly connected the symptoms-including the virus'
distinct blistering pattern-to smallpox. "We always believed we'd be knee-deep in bodies before anyone
realized what was happening. We were right. They had no idea what was going on," said the operations
supervisor of Pittsburgh's emergency operations center.156 To illustrate the point further, an emergency
department physician who had been through the domestic preparedness training estimated that numerous
people would have to be coughing up black blood, others on ventilators, and even dozens dead before he and
154 Note that in many locations, technicians still perform basic culture work on tabletops, without the benefit of safety
hoods and other high-level containment capabilities. Some concern was expressed that technicians, especially those in private
laboratories, could become symptomatic if they analyze certain cultures without strict safety precautions. Interviews with author:
Associate Hospital Administrator/Registered Nurse (13 November 1999); Physician, Hospital Department of Emergency
Medicine (24 March 1999). Laboratory staffs are taught to guard against respiratory and blood-borne pathogens and are
supposed to observe universal safety precautions, such as the use of eye protection and gloves. However, even the most
experienced technicians have lapses in judgment or safety. In the winter of 1989, Peter Jahrling, a veteran civilian virologist at
the US Army Medical Research Institute of Infectious Disease, encouraged a colleague to sniff the contents of a flask that he
thought contained a common soil bacterium.. Instead, photographs taken with a scanning electron microscope later revealed the
solution in the flask to be a filovirus, initially thought to be Marburg but later shown to be Ebola. Further violating safety
protocols, Jahrling did not inform his superior that he and his colleague had done a "whiff" test and therefore could be candidates
for isolation. Fortunately, the Ebola Reston strain, which decimated the test animals in a monkey house on the outskirts of
Washington, DC, did not species jump to humans. See C.J. Peters and Mark Olshaker, Virus Hunter: Thirty Years of Battling
Hot Viruses Around the World (New York: Anchor Books, 1997), 16, 235274. In a second case of apparently loose adherence
to biosafety practice at this facility, an Army scientist apparently contracted glanders, which is potentially fatal, because he was
not wearing gloves while working with the agent. "Army Scientist Who Contracted Rare Disease Worked Without Gloves,"
Associated Press, 26 June 2000; D. DeShazer et al., "Laboratory-Acquired Human Glanders-Maryland, May 2000," CDC
Morbidity and Mortality Weekly Report 49, no. 24 (23 June 2000): 533.
155 Interviews with author: Physician (29 May 2000); Registered Nurse/Chief, EMS Division, State Department of
Public Health (3 February 2000); Physician, Hospital Department of Emergency Medicine (24 March 1999).
156 Raymond DeMichiei, as quoted in Jonathan D. Silver, "Local Doctors Fail Their Test on Diagnosing Germ
Terrorism," Pittsburgh Post-Gazette, 13 February 2000. The occurrence of smallpox has been uncommon in the United States
since a worldwide campaign eradicated the disease in 1977. Seven emergency department physicians and eight inpatient
practitioners also participated in Dr. Michael Allswede's mini-survey. They were told that the patients initially had cold-like
symptoms, but several days later experienced nausea, diarrhea, and a facial rash that moved to the torso. Shown photographs of
people with blistering smallpox, the physicians were still stumped, considering lupus, toxic shock syndrome, and dozens of other
diseases, but rarely the variola virus.
252 Ataxia: The Chemical and Biological Terrorist Threat and the US Response
his colleagues understood anthrax was the cause.157 A 1998 survey of seventy-six physicians bolsters the
concern that most doctors would miss the clinical signs of a bioterrorist attack. Although 53 percent reported
that their emergency medicine residency programs included formal training in biowarfare agents, over 70
percent rated their ability to recognize bioterrorism casualties as very poor or less than adequate.158 These
statistics jibe with the assertion made by several interviewees: only when hospitals were swamped with the
ill would physicians finally recognize something was amiss and call the local health department.159 If
clinicians seeing a cluster of cases with similar symptoms considered certain factors, such as those listed in
box 6.6, worthy of further investigation, they would get a head start on discerning a terrorist attack from a
natural disease outbreak.
Ideally, public health officials and epidemiologists would be notified in a timely fashion so that
answers could be sought in a context broader than the initial cluster of cases or laboratory samples. If a
laboratory test or clinical diagnosis was not on hand to confirm an outbreak, the disease detectives would
order more tests to identify the pathogen. Epidemiologists would find and interview others with similar
symptoms, looking for temporal and geographic indicators of the identity and source of the disease. They
may refine their hypothesis with additional laboratory or environmental studies. From this basis, public
health authorities would design and implement measures to control the outbreak. Local and state officials
may begin this process, but they may soon call in the Epidemic Intelligence Service, the nation's cadre of
disease sleuths.160
157 Interview with author: Physician/Associate Director, Hospital Department of Emergency Medicine (9 March 1999).
Other medical professionals offering similar opinions about the ability of medical staff to detect infectious diseases: Physician
(29 May 2000); Registered Nurse/Chief, EMS Division, State Department of Public Health (3 February 2000); Associate
Hospital Administrator/Registered Nurse (13 November 1999); Project Manager, Emergency Management Planning (27 July
1999); EMS Superintendent-in-Chief (24 March 1999). Bartlett, "Applying Lessons Learned from Anthrax Case History to Other
Scenarios," 5613.
158 Pesik, Keim, Sampson, "Emergency Medicine Residency Program Training for Bioterrorism," 175.
159 Interviews with author: Director, Emergency Services Department (18 May 2000); Registered Nurse/Chief, EMS
Division, State Department of Public Health (3 February 2000); Associate Hospital Administrator/Registered Nurse (13
November 1999); Project Manager, Emergency Management Planning, (27 July 1999); Physician, Hospital Department of
Emergency Medicine (24 March 1999); EMS Superintendent-in-Chief (24 March 1999); Physician/Associate Director, Hospital
Department of Emergency Medicine (9 March 1999).
160 Wetterhall, "Surveillance Systems,"1-1056. For insight into what it is like to be a disease sleuth, see Peters and
Olshaker, Virus Hunter.
Chapter 6 Metropolis, USA: Progress, Pitfalls in Front-line Readiness 253
Box 6.6: Epidemiologic Clues to a Possible Bioterrorist Attack
* A distribution of cases that is inconsistent with normal disease patterns (geographically and/or
temporally), with greater than anticipated numbers of patients, especially in a distinct population;
* More severe illness than is typical for a given pathogen, as well as unusual routes of exposure (e.g.,
inhalational anthrax as opposed to cutaneous or gastrointestinal cases);
* A disease that is not endemic to a given geographic area, unusual for the time of year, or impossible to
transmit naturally since the disease carrier (e.g., mosquito, rodent) is not present in the area;
* Simultaneous upswings of different diseases;
* A disease outbreak affecting animal and human populations;
* Unusual strain of a disease or atypical antibiotic resistance patterns;
* Higher rates of disease among those who were located in certain areas at a certain point in time (e.g.,
inside a building where agent was released, outside if the attack was outdoors);
* Intelligence data that a nation or terrorist group possessed a certain biowarfare agent or agents;
* Claim(s) by a terrorist group to have released a biological agent;
* Direct evidence (e.g., environmental samples, delivery system) that an agent was released.
Sources: Julie A. Pavlin, "Epidemiology of Bioterrorism," Emerging Infectious Diseases 5, no. 4
(July/August 1999): 529; Robert P. Kadlec, Alan P. Zelicoff, Ann M. Vrtis, "Biological Weapons Control:
Prospects and Implications for the Future," Journal of the American Medical Association 278, no. 5 (6
August 1997): 355.
One of the misimpressions about a covert biological attack is that it would not be possible to tell a
natural outbreak from a purposeful act.161 Public health authorities scrutinizing the data would recognize
at a certain juncture that an outbreak was terrorist-driven, but depending upon the disease and the location
of the attack, months could pass before that conclusion was reached. Such was the case with a cult's
poisoning of salad bars in The Dalles, Oregon, with salmonella late in the summer of 1984.162 The summer
1999 outbreak of West Nile virus in the New York City area was another case that demonstrated this
161 "In most naturally occurring epidemics, there is a gradual rise in disease incidence, as people are progressively
exposed to an increasing number of patients, vectors, or fomites that spread the pathogen. In contrast, those exposed to a
[biological weapons] attack would all come in contact with the agent at approximately the same time. Even taking into account
varying incubation periods based on exposure dose and physiological differences, a compressed epidemic curve with a peak in a
matter of days, or even hours, would occur." David R. Franz et al., "Clinical Recognition and Management of Patients Exposed
to Biological Warfare Agents," in Biological Weapons: Limiting the Threat, ed. Joshua Lederberg (Cambridge, Mass.: The MIT
Press, 1999), 778.
162 Thomas J. Torok et al., "A Large Community Outbreak of Salmonellosis Caused by Intentional Contamination of
Restaurant Salad Bars," Journal of the American Medical Association 278, no. 5 (6 August 1997): 38995. This case is
described in box 2.2 in chapter 2.
254 Ataxia: The Chemical and Biological Terrorist Threat and the US Response
difficulty.163 Whereas these cases were tough to identify as purposeful or naturally occurring incidents,
the appearance of a single case of smallpox or inhalational anthrax would immediately be suspect.
Efforts to Improve the Early Detection of Disease Outbreaks
Some public health officials and emergency planners are striving to find speedier ways to detect
an unusual rise in illness. Many critically ill people make their way into the health care system via the
EMS, so several concepts for auditing fluctuations in the number of patients admitted to hospitals work
off of EMS activity levels. In some cities, doctors interact with paramedics and EMTs throughout their
shifts, advising them on pre-hospital treatment and discussing unusual inbound cases. Because doctors
supervising EMS personnel are information choke points about community health problems, they might
spot a disease outbreak early in its progression.164 In other EMS-based surveillance approaches, cities
have begun to establish capacities to monitor the number of incoming patients and the diversion status
of hospitals as well as incoming patients with similar symptoms.165 Similarly, a few states have
instituted a state wide system to recognize an elevation in hospital admissions. EMS crews and hospital
emergency departments must inform the attending emergency doctor or charge nurse in a designated area
hospital when they see a rapid or developing rise in patients with similar symptoms. In turn, the
designated area hospital notifies the state public health department if two or more of the hospitals in its
area network are experiencing a hike in same-symptom cases. State public health officials then
determine if something out of the ordinary is taking place.166
163 This outbreak caused seven deaths in humans and spread widely through the bird and mosquito populations. At
first, the CDC thought it was St. Louis encephalitis, but the alertness of a Bronx Zoo pathologist was the key to unraveling the
mystery. For case analyses, see Monica Schoch-Spana, "A West Nile Virus Post-Mortem," Biodefense Quarterly 1, no.3
(December 1999): 12, 68; Janet Heinrich, West Nile Virus: Preliminary Information on Lessons Learned, GAO/HEHS-00-
142R (Washington, DC: US General Accounting Office, 23 June 2000). To track the spread of the West Nile virus in different
areas of the country, go to: http://nationalatlas.gov/virusmap.html.
164 The paramedics on their own are good lookouts for budding health care problems. For instance, they have always
been the first to perceive when a bad batch of drugs has been shipped into one city because the volume of drug overdoses rises
dramatically. About 85 percent of the nation's cities have incorporated their EMS service into the fire department, but cities such
as Boston, Denver, Cleveland, and Minneapolis operate their EMS as a third service, wherein physician supervision of
paramedics and EMTs is described as particularly close. Interviews with author: EMS Superintendent-in-Chief (24 March
1999); Physician/Associate Director, Hospital Department of Emergency Medicine (9 March 1999).
165 One city operates a website that enables an aggregate hospital capacity census every eight hours. Another requires
EMS crews to track hospital status and notify the health department of two or more cases with similar symptoms within a day. A
third has a computerized system keeping tabs on key parameters (e.g., number of admissions, gastro-intestinal and respiratory
complaints) every twelve hours, initiating an investigation if data exceed standard deviations. Interviews with author:
Physician/Director of Health, Public Health Department (20 September 2000); Battalion Fire Chief, Special Operations (25 May
2000); Registered Nurse/Emergency Planner, Public Health Department (7 April 2000).
166 Every year, the influenza season provides a natural test for this system and validates its utility in helping to manage
health care. This type of alert system is also useful in a heat emergency or a natural communicable disease epidemic. Note that
EMS dispatch personnel could report the rise in same-symptom patients, and the poison control center may also be contacted.
The number of same-symptom patients that must be seen to trigger notification is not specified. As appropriate, the public health
department sends out a blast facsimile to hospitals and to the EMS services throughout the state to let them know that they might
Chapter 6 Metropolis, USA: Progress, Pitfalls in Front-line Readiness 255
The syndrome surveillance approaches being tried to achieve early detection of a suspicious disease
outbreak, described in boxes 6.7 and 6.8, constitute something of a departure for public health monitoring.
Rather than waiting for laboratory identification, data about disease types and rates are collated from various
sources, allowing the geographic and temporal evolution of a disease through a given area to be mapped.
This data can arm public health officials to differentiate between disease patterns, to deduce whether an
outbreak is natural and the disease in question is contagious.167 These prototypes expand past EMS entry
into the health care system to encompass the other avenues to medical care, such as over-the-counter
medication sales, private practice doctors, and the primary care clinics of health maintenance organizations.
The more data points incorporated, the more useful these systems may be, not just to detect a covert
bioterrorist attack, but to handle routine public health problems more effectively.
Unless such reporting is required by law, active disease surveillance systems will depend to a large
extent upon the willingness of health care personnel to supply voluntarily, promptly, and regularly the data
that power these analytical tools. Since health care providers stand to gain measurably from tools that
improve the ability to detect disease outbreaks, their interest and hopefully their cooperation can be
assumed.168 As these prototypes are refined, a strong case could be made not just for city governments, but
for the country as a whole to institute an active disease surveillance system. The power of this type of
disease tipoff tool has yet to be proven for naturally occurring or deliberately caused disease outbreaks, but
the promise of syndrome surveillance may explain why a few other metropolitan areas have already begun
start seeing an increase in patients. If the influx of patients compels two or more hospitals in an area to go on bypass and EMS
crews must travel more than ten minutes to reach an open hospital, then the public health department regulations mandate that
hospitals come off bypass. Interview with author: Registered Nurse/Chief, EMS Division, State Department of Public Health (3
February 2000). Other states are also setting up computerized information exchanges between hospitals and a statewide data
system to track the flux and characteristics of hospital cases based on EMS records. Interviews with author: Director, Emergency
Services Department (18 May 2000); EMS System Analyst/Paramedic, State Department of Health and Social Services (25
January 2000).
167 For example, if numerous elderly adults report with fever, fatigue, and aching joints in the middle of winter, public
health care officials would suspect influenza. However, if otherwise healthy young adults report the same symptoms, then
another microbe may be causing the illness. Contagious diseases have identifiable cycles, so public health officials can predict
and prepare for when the next wave of patients would seek medical care. Smallpox, for example, has an average incubation
period of twelve days. Interview with author: Physician (29 May 2000).
168 Skepticism was voiced that hard-pressed medical personnel would take the time to fill out such forms. Interview
with author: Physician, Division of Disease Control, Public Health Department (8 August 2000).
256 Ataxia: The Chemical and Biological Terrorist Threat and the US Response
Box 6.7: Cuing Early Recognition of Disease Outbreaks-Prototype I1
In New York City, public health and city emergency authorities have established novel tools
to try to detect outbreaks of disease as early as possible to give the health care system more time to
respond effectively. Eleven sentinel public hospitals report daily to the public health department on
the number of hospital admissions through the emergency department. In the future, the number of
sentinel hospitals may be expanded and additional data requested, such as the number of patients with
selected diagnoses on admission or discharge from the emergency department or ICU or other data on
clinical syndromes. The city is also tracking patterns of 911 calls, focusing on seven call types
correlated with flu-like illness. Each morning, city public health officials receive aggregate data from
the following selected call types over the previous twenty-four hours: 1) difficulty breathing; 2)
respiratory distress; 3) minor sickness; 4) adult sickness; 5) pediatric sickness; 6) adult asthma; and, 7)
pediatric asthma. Calls reporting abdominal pain are monitored as a control. To choose these call
categories from the total of sixty-three call types, city officials reviewed data back to 1991 and found
that rises in the frequency of these call types correlated to influenza outbreaks. These historical 911
data was analyzed and modeled to control for other factors that can effect the number of cases,
including season of the year, day of the week, weather, temperature, and humidity. A statistical
baseline was established and thresholds were identified to trigger an investigation of a possible covert
bioterrorist attack. The health department also monitors unexplained deaths due to possible infectious
disease among those ranging in age from two to forty-nine using death certificate data that is usually
filed within seventy-two hours and retrieved daily for review.
Before creating these tools for early detection of flu-like illness, New York City had previous
experience with using alternative sources of data to ascertain a rise in disease syndromes associated
with water-borne illnesses. The health department receives reports every day from one commercial
and two public laboratories on the number of stool samples submitted for bacterial culture and
parasitic examination. A second daily report comes from eleven sentinel nursing homes dispersed
around the city, which chronicle the onset on new diarrhea cases. A third report arrives weekly from a
wholesale distributor that tracks the sales of over-the-counter anti-diarrheal medications (e.g.,
Kaopectate). Traditional laboratory analyses can reliably identify and trigger reports of disease, but
an upsurge in diarrheal cases could tip officials off to a water-borne disease outbreak long before
physician or laboratory diagnosis occurs.
To augment the city's flu-like syndrome surveillance, public health officials are considering
several additional measures to capture still other entry routes to the health care system. First, the
health department may monitor levels of school absenteeism, sick calls into employee health clinics
for firefighters, police, and public transportation personnel, and outpatient calls to the hotlines that
health maintenance organizations use to direct patients to medical care. Second, public health
officials may track the sale of over-the-counter drugs for flu-like symptoms. Consumers buy these
products to treat colds and general malaise, not just influenza, so city officials are weighing whether to
watch just a few products or this entire class of over-the-counter medications.
NOTES
1. For more information on New York City's approach, please contact the Communicable Disease Program at the New York
City Department of Health. This description was compiled from the author's interviews with individuals from that program
and the Mayor's Office of Emergency Management. In 1995, the Environmental Protection Agency required the city to
establish a sentinel reporting system to watch for an unusual upswing in the occurrence of water-borne disease because the
city's water system is chlorinated, but not filtered. As additional precautions, New York City purchased land adjacent to city
reservoirs and instituted a program to reduce run-off of agrochemicals and agricultural waste from farms.
Chapter 6 Metropolis, USA: Progress, Pitfalls in Front-line Readiness 257
Box 6.8: Cuing Early Recognition of Disease Outbreaks-Prototype II1
Various hospitals in New Mexico and the state public health department have begun testing a
syndrome surveillance system designed to help differentiate normal cycles of disease from a possible
bioterrorist attack. From touch-screen computers in emergency departments and urgent care clinics,
doctors have begun documenting patient admissions for five different causes: 1) flu-like illness; 2)
mental status changes with fever; 3) fever and skin rash; 4) hepatitis/acute jaundice; and, 5) diarrhea
with fever. After filling in a patient's demographic data (e.g., zip code, occupation, gender, age) and
selecting a syndrome area, doctors use a second pull-down screen to add details about the patient's
status and the diagnostic tests ordered. The entire data entry process takes less than a minute.
The data are transmitted in real time and tabulated in a central database in the New Mexico
Department of Health. Within seconds, the doctor who just filed the entry begins to see raw
epidemiological data as geographic and temporal maps pop up on the computer screen. A color-coded
map indicates areas where the five disease syndromes exist or are on the rise, and another map charts
the evolution of the syndrome over a rolling thirty-day period. The physician also sees a summary of
numbers and results of all viral cultures recently ordered in the area and related alerts from the state
health department. This information enables the doctor to learn right away whether the patient being
treated is an isolated case or part of a more widespread pattern of illness. Such data can be important
to differential diagnosis and initial treatment. In addition to helping local physicians understand what
is happening in their communities, this system is a decision aid for state health care authorities who
might manage a budding health care crisis with a variety of measures (e.g., increasing shipments of
medicines, controlling access into and out of an affected area).
NOTES
1. For more information on this prototype, contact Dr. Alan Zelicoff at Sandia National Laboratories' Center for National
Security and Arms Control. This description was compiled from the author's interview with Dr. Zelicoff and written
information that he provided. The prototype was funded with $50,000 from the Department of Energy. Dr. Zelicoff expected
to have data on the prototype's performance late in 2000. Note that the prototype protects patient privacy with encoding
software.
to adopt New York City's plan.169 With the cooperation of health care personnel in Atlanta, Seattle,
Philadelphia, and Los Angeles, the CDC also has begun to test its own variant of an active syndrome
surveillance system.170 Public health officials, the medical community, and emergency planners appear to
169 In one instance, basic 911 call monitoring had already been instituted in 1999 to forewarn officials of a possible heat
stress crisis, flagging anything above a 10 percent increase in the daily calls for EMS service. Interviews with author: Emergency
Management Specialist, Office of Emergency Management (9 May 2000); Physician/EMS Medical Director (13 November
1999); Physician, Hospital Department of Emergency Medicine (24 March 1999).
170 The Seattle test was conducted in conjunction with the World Trade Center meeting in December 1999; the
Philadelphia test took place around the Republican National Convention from 27 July to 4 August 2000; and the Los Angeles
test, likewise, was during the Democratic National Convention from 14 to 17 August 2000. In Philadelphia, the template
included surveillance at first aid stations, hospital census data (e.g., number of emergency department, ICU, and regular
admissions and number of deaths), and sentinel emergency department surveillance data. The latter activity tracked patients
presenting with the following disease syndromes: 1) respiratory tract infection with fever; 2) diarrhea/gastroenteritis; 3) rash and
fever; 4) sepsis and/or acute shock; 5) meningitis/encephalitis; 6) botulism-like syndrome; 7) unexplained death with history of
fever; 8) none of the above; and 9) no box checked on form. Of the 4,959 reports received during the specified time period, 96.4
percent were in the latter two categories. "Summary and Final Report: Infectious Disease Surveillance," Bulletin 10
(Philadelphia: Department of Public Health, 11 August 2000), 1, 4. The CDC's earliest test took place during the 1996 Atlanta
258 Ataxia: The Chemical and Biological Terrorist Threat and the US Response
be on their way to devising and refining workable tools to recognize disease outbreaks in their infancy, in
which case they will have overcome a tremendously difficult challenge. That feat, however, somewhat pales
in comparison to putting plans and capabilities in place to cope with the consequences of a pathogen running
amok through the human population.
Providing Public Health Care in the Midst of Panic
One thing that the health care community would have working in its favor after a bioterrorist attack
is that medical therapies for most biowarfare agents are available, although some therapeutic regimens are
experimental and lack Food and Drug Administration approval. For some biowarfare agents, the
administration of vaccines and/or antibiotics soon after exposure would prevent the disease from maturing
in those already infected or protect those who were not originally exposed from getting the disease. Medical
therapies have been published in the military literature and, increasingly, in leading medical journals.171
Health care authorities in several cities have used such sources to develop their own protocols for pre-
hospital and hospital treatment.172 A 25-member panel of experts, sponsored by the Health and Human
Services Department, also has been charged with developing consensus guidelines for recognition and
treatment of ten biowarfare agents.173
Knowing which antibiotics to administer is one thing; having a sufficient supply to treat an eighth,
a quarter, a half, or all of the citizens in a large US city is another thing entirely. To cut costs, hospitals have
switched to just-in-time stocking of medicines, usually keeping on hand only enough to last two, at most
three, days. Supplies are re-stocked daily.174 Once an outbreak is identified, one of the first calls made from
Olympics. Interview with author: General Manager, Emergency Department (22 September 2000).
171 Medical Management of Biological Casualties: Handbook, 3rd ed. (Frederick, Md.: US Army Medical Research
Institute of Infectious Diseases, July 1998); Sidell, Takafuji, and Franz, eds., Medical Aspects of Chemical and Biological
Warfare; Thomas V. Inglesby et al., "Plague as a Biological Weapon: Medical and Public Health Management," Journal of the
American Medical Association 283, no. 17 (3 May 2000): 228190; Thomas V. Inglesby et al., "Anthrax as a Biological
Weapon: Medical and Public Health Management," Journal of the American Medical Association 281, no. 18 (12 May 1999):
173545.
172 Interviews with author: Director, Emergency Services Department (18 May 2000); Registered Nurse/Chief, EMS
Division, State Department of Public Health (3 February 2000); Project Manager, Emergency Management Planning (27 July
1999).
173 These guidelines will contain symptom-based presentations of what the patients would experience, say, and manifest
clinically. Information will be presented in a Cliff's notes-like format, in "if X and Y, then treat this way" bullets, followed by a
flow chart showing disease presentation, progression, and treatment. Interview with author: Toxicologist, Poison Control Center
(15 June 2000).
174 Interviews with author: former State Epidemiologist (18 August 2000); Emergency Planner, Hospital Health
Maintenance Organization (15 August 2000); Physician, Division of Disease Control, Public Health Department (8 August
2000); Physician, Hospital Division of Emergency Medicine (31 May 2000); Emergency Management Specialist, Office of
Emergency Management (9 May 2000); Physician/Director of Hospital Disaster EMS (27 July 1999); Project Manager,
Emergency Management Planning, Office of Emergency Management (27 July 1999).
Chapter 6 Metropolis, USA: Progress, Pitfalls in Front-line Readiness 259
a city's emergency operations center, described in box 6.3, would be to request the national pharmaceutical
stockpile.175 This stockpile is stored in eight locations around the United States. The CDC pledges to get
these medications to a city within twelve hours, accompanied by a small staff to help distribute the cache.176
Just getting the medications to a city is not even half of the battle. The stockpile would do the local citizens
no good if it sits on the airport tarmac. Local authorities need to have detailed plans and assigned personnel
in place to disburse the drugs promptly to various facilities.177
Much of the national stockpile consists of antibiotics, partly because supplies of vaccines are not
particularly deep. For most biowarfare agents, there are no vaccines approved for civilian use.178 Moreover,
there are assorted problems with the licensed vaccines. The cholera vaccine, for example, has only a 50
percent efficacy when used in areas where the disease is endemic. Manufacture and sale of the cholera
vaccine was discontinued in August 2000.179 Supplies of vaccines for anthrax, plague, and smallpox are
limited. The anthrax vaccine, which is effective against aerosol transmission, is given in a six-shot series
over an eighteen-month period. Financial problems caused the one firm that manufactured this vaccine to
halt production in December 1999. By mid-July 2000, the Pentagon had only 165,000 doses of anthrax
vaccine left.180 Antibiotics can be administered until vaccine is available, but if eight million people were
175 Interviews with author: Director, Emergency Services Department (18 May 2000); Paramedic (12 May 2000);
Emergency Management Specialist, Office of Emergency Management (9 May 2000); Physician/EMS Medical Director (13
November 1999); Project Manager, Emergency Management Planning (27 July 1999).
176 The stockpile reportedly contains antibiotics for over 114,000 people. The CDC has arrangements with drug
suppliers that may increase the availability of antibiotics to roughly five million doses within thirty-six hours. Pharmaceutical
companies say that it would be difficult to manufacture additional supplies quickly, partly since most have converted to just-in-
time inventory control practices. Osterholm and Schwartz, Living Terrors, 1301.
177 On the importance of distribution plans: former State Epidemiologist (18 August 2000); Physician, Division of
Disease Control, Public Health Department (8 August 2000); Physician, Hospital Division of Emergency Medicine (31 May
2000). One city plans to have the stockpile land at a nearby Air National Guard hangar, with state health department personnel
in charge of distribution. Interview with author: Battalion Fire Chief, Special Operations (25 May 2000). On the travails
encountered in notionally distributing the stockpile during the Denver segment of the mid-May 2000 Topoff drill, where a plague
release was simulated, see Inglesby, Grossman, and O'Toole, "A Plague on Your City: Observations from TOPOFF."
178 Vaccines do not exist for brucellosis, glanders, viral hemorrhagic fevers, Staphylococcal enterotoxin B, ricin, and T-
2 mycotoxins. David R. Franz et al., "Clinical Recognition and Management of Patients Exposed to Biological Warfare Agents,"
Journal of the American Medical Association 278, no. 5 (6 August 1997): 4001; Medical Management of Biological
Casualties, Appendix H.
179 Philip K. Russell, "Vaccines in Civilian Defense Against Bioterrorism," Emerging Infectious Diseases 5, no. 4
(July/August 1999): 5323. Two other cholera vaccines are made in Sweden and Switzerland, but are not available in the United
States. According to the CDC, the Wyeth Ayerst vaccine provided "brief and incomplete immunity." Centers for Disease Control
and Prevention, "Update on Cholera Vaccine." Internet: www.cdc.gov/travel/other/cholera-vaccine.htm. Downloaded 19
September 2000.
180 Among other problems with the anthrax vaccine, it must be produced in high-containment facilities because of the
spore-forming property of Bacillus anthracis. The method employed pre-dates molecular biology, and the level of extraneous
proteins and purity in the resulting vaccine are less than ideal. Finally, the current vaccine may not be effective against
genetically engineered strains of anthrax developed in the USSR's biowarfare program. Russell, "Vaccines in Civilian Defense
Against Bioterrorism," 5323. BioPort Corp. in Lansing, Michigan, is the maker of the anthrax vaccine. Andrea Stone, "Audit:
260 Ataxia: The Chemical and Biological Terrorist Threat and the US Response
possibly exposed to anthrax, over $1 billion worth of ciprofloxacin would be needed to treat them for the
sixty days required to make enough vaccine.181
As for the plague vaccine, it protects against transmission of the disease by fleas, but is not effective
against pneumonic plague or aerosol transmission. This vaccine is also no longer being produced.182 The
condition of the nation's stocks of smallpox vaccine is deteriorating and supplies are sufficient to immunize
under seven million people. No US company employs the time-consuming, traditional method required to
make this vaccine, so at least thirty-six months would be required to produce large quantities.183 In mid-2000,
a study was underway to determine whether the efficacy of the existing vaccine stockpile could be
maintained if it were diluted by a factor of three, ten, or a hundred, enabling many more people to be
covered.184 The CDC also announced the hiring in mid-September 2000 of a firm to manufacture forty
million doses of the new smallpox vaccine, made with modern, cell culture methods. Since the new vaccine
still has to undergo clinical testing, the first deliveries were scheduled to occur in the mid-2004 timeframe.185
Vaccine Producer Needs Bailout," USA Today, 13 April 2000; Elaine Sciolino, "Anthrax Vaccination Program Is Failing,
Pentagon Admits," New York Times, 13 July 2000. On the vaccine and antibiotic resistant strains of anthrax, see Alibek with
Handelman, Biohazard, 160, 167, 261, 281.
181 David W. Siegrist, Hot Zone `99: Advanced Technology Needs for Consequence Management of Biological
Terrorism (Arlington, Va.: Potomac Institute for Policy Studies, 1999), 17.
182 Russell, "Vaccines in Civilian Defense," 5312.
183 The CDC estimates that there are 15.4 million doses of smallpox vaccine, of which experts believe there are
between seven and eight million usable doses. Not only has condensation been found in the tubes in which the freeze-dried
vaccine crystals are stored, the fluid needed to dilute the vaccine has decayed. Worldwide there are less than one million of the
two-pronged needles needed to administer the vaccine. No company currently manufactures these special needles. Finally, only
675 doses are left of vaccinia immune globulin, and even that supply may be unusable. This drug helps patients who have had a
severe reaction to the vaccine. Various nations store an estimated one million doses of the vaccine in unknown condition; the
World Health Organization has an additional 500,000 dose stockpile. With the vaccine in such short and questionable supply,
perhaps two billion would perish if smallpox were released. The last outbreak of smallpox was in Yugoslavia in 1972 and
required the administration eighteen million doses of vaccine in ten days to contain it. Osterholm and Schwartz, Living Terrors,
142. Also, D.A. Henderson, "Smallpox: Clinical and Epidemiologic Features," Emerging Infectious Diseases 5, no. 4
(July/August 1999): 538; D.A. Henderson, "Bioterrorism as a Public Health Threat," Emerging Infectious Diseases 4, no. 3
(July-September 1998). Internet: http://www.cdc.gov/ncidod/eid/vol4no3/hendrsn.htm; Laurie Garrett, Betrayal of Trust: The
Collapse of Global Public Health (New York: Hyperion, 2000), 5246.
184 The results of this study, which is being conducted by St. Louis University, are expected at the close of 2000. Scott
R. Lillibridge, director, Bioterrorism Preparedness and Response, National Center for Infectious Diseases, CDC. Presentation at
the Conference on Health Care Response to Bioterrorism, 5 June 2000, San Francisco, California.
185 Ronald Rosenberg, "Oravax in $343M Contract to Develop Smallpox Vaccine for Government," Boston Globe, 21
September 2000.
Chapter 6 Metropolis, USA: Progress, Pitfalls in Front-line Readiness 261
Research, development, and testing of vaccines against seven biological agents is also underway,186 but the
clinical trial process is expected to be difficult and lengthy.
In the interim, until the national drug stockpile arrives, some cities have received federal grant funds
via the MMRS program to purchase a local pharmaceutical cache that can serve as a stopgap. City officials
are worried that federal or local monies would not be provided to replace the antibiotics, which expire within
a few years.187 A number of cities approached major pharmaceutical warehouses in their areas to try to
obtain agreements whereby the warehouses would provide drugs in an emergency and identify year-round,
around-the-clock points of contact. These efforts have met with mixed results.188 Chapter 5 describes
alternative strategies that have proven extremely effective in saving drug purchase dollars, such as employing
the Shelf Life Extension program and building a pharmaceutical "bubble" into the local health care system.189
Aside from medications, a city would need extra quantities of all of the other supplies required to
care for the ill, from sheets and intravenous fluids to tongue depressors. Some of these supplies would come
186 Vaccines against tularemia, Q fever, Botulinum toxoids, Bolivian hemorrhagic fever, Argentine hemorrhagic fever,
Rift Valley fever, and Venezuelan, Eastern, and Western equine encephalitis are categorized as investigational new drugs. Franz
et al., "Clinical Recognition and Management of Patients," 4001; Medical Management of Biological Casualties: Handbook,
Appendix I; Russell, "Vaccines in Civilian Defense," 531. Testing of these vaccines is being conducted under the Pentagon's
Joint Vaccine Acquisition Program. See, "Army Pursues Joint Vaccine Acquisition Program," press release no. 9759
(Washington, DC: US Army, Office of Public Affairs, 12 June 1997); "Joint Vaccine Acquisition Program: Questions and
Answers" (Frederick, Md.: Joint Vaccine Acquisition Program, Program Management Office, n.d.).
187 Interviews with author: EMS Chief, Emergency Services Department (21 September 2000); Physician, Division of
Disease Control, Public Health Department (8 August 2000); Pre-Hospital Care Coordinator/Emergency Planner (2 May 2000);
Registered Registered Nurse/Emergency Planner, Public Health Department (7 April 2000); Fire Captain/Assistant Emergency
Management Coordinator (5 January 2000); Battalion Fire Chief/Emergency Services Administrator (15 November 1999);
Emergency Preparedness Director, Office of Emergency Services (9 February 1999); Emergency Preparedness Director, Office of
Emergency Services (9 February 1999); Director, Office of Emergency Services (4 February 1999).
188 One city has a memorandum of understanding with local warehouses, stipulating which medications would be sent
in a chemical, biological, or nuclear incident. Prices are fixed. Interviews with author: Emergency Planner, Hospital Health
Maintenance Organization (15 August 2000); Battalion Fire Chief, Special Operations (25 May 2000). Another city has a verbal
agreement with two local warehouses to supply enough antibiotics to treat 100,000 for three days. The warehouses have supplied
24-hour points of contact, and distribution and security plans have been settled with local sheriffs. Interview with author:
Physician/University Hospital Department of Emergency Medicine (20 September 2000). Two cities had queried drug
warehouses on several occasions to see how much of "X" drug they could obtain on the spot. Interviews with author: Fire EMS
Statistician (30 August 2000); Physician, Division of Disease Control, Public Health Department (8 August 2000). One large
urban hospital cut its own deal with a local warehouse. Interview with author: Physician, Hospital Division of Emergency
Medicine (31 May 2000). Other locals have been rebuffed by local drug warehouses. Interviews with author: Emergency
Management Specialist, Office of Emergency Management (9 May 2000); Registered Nurse/Chief, EMS Division, State
Department of Public Health (3 February 2000); Physician/Hospital Department of Emergency Medicine (15 June 1999).
189 Manufacturers do not guarantee the efficacy of a drug past its expiration date. For example, Bayer sets the shelf life
of ciprofloxacin at three years. Pharmacists in some states are required to shorten the expiration date on any drug not dispensed
in original packaging to one year. Elsewhere, pharmacists also adopt this practice. As discussed in more detail in chapter 5,
testing has shown that several medications, including ciprofloxacin, were still 90 percent viable ten years after their expiration
date. Laurie P. Cohen, "Safe and Effective: Many Medicines Prove Potent for Years Past Their Expiration Dates," Wall Street
Journal, 28 March 2000.
262 Ataxia: The Chemical and Biological Terrorist Threat and the US Response
with the national stockpile. Others will have to be obtained from local companies. In two cities, hospitals
individually checked with their suppliers to ensure that emergency orders could be filled, each receiving
assurances from vendors to that effect. Only later during a citywide planning meeting did the hospitals make
the eye-opening discovery that they all relied on the same few contractors, which made it improbable that
the suppliers could keep their promises to everyone. Emergency supply plans were adjusted accordingly.190
Volunteer agencies such as the Red Cross, as well as the National Guard and the Federal Emergency
Management Agency, will be asked to help with some types of emergency supplies (e.g., cots, blankets,
water).191
A well-coordinated media game plan will be essential to reassure the public and attempt to manage
the crisis. Even with careful media relations, public health and emergency response officials anticipate a
widespread panic of the kind inspired by Orson Welles' 1938 "War of the Worlds" radio broadcast, except
worse, much worse.192 People frightened that they were exposed to this invisible thing would flock to the
hospitals for checkups and treatment. The mass psychogenic effects would be even more pronounced than
for poison gas attack because of the incubation period and common, flu-like symptoms brought on by many
biological agents. Hospitals that have already seen genuinely ill patients would soon be swamped by more
infected patients and the worried well. To wit, the ratio of worried well to infected patients during the 1993
outbreak of hantavirus in the Four Corners area was 10 to 1.193
Given the widespread recognition that hospitals would buckle quite quickly under such a burden,
local emergency planners and hospitals in some cities are collaborating on workable patient management
plans for both the ill and worried well. In the late 1990s, the patient load of a regular influenza season
overtaxed primary care facilities. So, in an epidemic, already scarce ICU beds would be snapped up, and,
if a contagious disease were involved, hospital capacity to isolate patients would be rapidly exceeded.
190 Interviews with author: Emergency Planner, Hospital Health Maintenance Organization (15 August 2000);
Physician, Hospital Division of Emergency Medicine (31 May 2000); Battalion Fire Chief, Special Operations (25 May 2000).
Also commenting on this problem in the Denver segment of the mid-May 2000 Topoff exercise: Senior CDC official (29 August
2000).
191 Interviews with author: Fire EMS Statistician (30 August 2000); Director, Emergency Services Department (18 May
2000); Paramedic (12 May 2000).
192 This infamous broadcast, which described Martians landing on earth, incited terror across the country. A Princeton
University study estimated that more than one million of the six million listeners believed that an alien invasion was indeed
taking place. Some hysterical listeners committed suicide and others fled their homes, causing traffic jams in the Northeast.
Police, fire and newspaper lines were flooded with calls. People swore that they could see the flames or smell the gas from the
fictional Martian attacks. "Radio Listeners Panic, Taking War Drama as Fact," New York Times, 31 October 1938; Mike
Flanagan, "The First Star Wars Fifty Years Ago, Orson Welles Panicked America with a Single Broadcast," Chicago Tribune, 30
October 1988.
193 Interview with author: Director of Hospital EMS and Disaster Medicine (19 April 1999). The hantavirus
investigation was triggered by an odd cluster of deaths in otherwise healthy young Navajos. For the story of how CDC and Army
scientists tracked the virus to its vector, the Peromyscus maniculatus deer mouse, and isolated and identified the Four Corners
virus, see Garrett, "All in Good Haste," Coming Plague, 52849.
Chapter 6 Metropolis, USA: Progress, Pitfalls in Front-line Readiness 263
"There is no give in the system for an incident of any magnitude," observed one physician.194 Guidance is
available to help individual hospitals adjust their plans to cope with an abrupt and considerable rise in
infectious disease patients, centering on the handling of anthrax, botulism, plague, and smallpox cases.195
As the crisis mounts, hospitals would probably have little choice but to designate entire wards, wings, and
even facilities to the care of infectious disease cases.196 Such actions would be so disruptive to routine health
care services that in the current health care environment many find them difficult to contemplate. The terms
of regional hospital burden-sharing need to be set far in advance of a health care crisis, and very few
metropolitan area hospital planning committees have begun to broach the level of detail and collaboration
required, much less put the finishing touches on such plans.197
Several cities have a two-fold strategy to try to keep the hospitals from collapsing under this human
tidal wave. They plan to establish a surge capacity at the hospitals as well as medical outposts away from
them. Cities are attempting to create an overflow capacity adjacent to or nearby hospitals, in buildings or
194 Interview with author: Physician, Hospital Department of Emergency Medicine (24 March 1999). Seconding the
hospital capacity problem: Physician/University Hospital Department of Emergency Medicine (20 September 2000);
Physician/Director of Health, Public Health Department (20 September 2000); Fire EMS Statistician (30 August 2000); former
State Epidemiologist (18 August 2000); Emergency Planner, Hospital Health Maintenance Organization (15 August 2000);
Physician, Division of Disease Control, Public Health Department (8 August 2000); Medical Toxicologist/Poison Control Center
Director (13 June 2000); Physician, Hospital Division of Emergency Medicine (31 May 2000); Paramedic (12 May 2000);
Registered Nurse/Chief, EMS Division, State Department of Public Health (3 February 2000); Physician/EMS Medical Director
(13 November 1999); Project Manager, Emergency Management Planning (27 July 1999); EMS Superintendent-in-Chief (24
March 1999). Note that the number of beds does not equate to beds that are functionally available because the latter category
cannot be opened without staff. Isolation requires negative airflow rooms, the ability to compartmentalize ventilation systems so
that patients with communicable diseases do not infect other patients. A 1998 survey by the Minnesota Department of Health
found that of the 144 hospitals statewide that provided acute care services, a total of sixty negative air-pressure units with 465
beds were available. The size of the units ranged from one to seventy-five beds. Only 108 of the beds in negative-pressure units
were also ICU beds. Osterholm and Schwartz, Living Terrors, 1389. See also, Inglesby, Grossman, and O'Toole, "A Plague on
Your City: Observations from TOPOFF."
195 The Association for Professionals in Infection Control and Epidemiology prepared a model plan in conjunction with
the CDC. See Judith F. English et al., The Bioterrorism Readiness Plan: A Template for Healthcare Facilities (Washington, DC:
Association for Professionals in Infection Control and Epidemiology, 13 April 1999). Internet:
www.apic.org/html/educ/readinow.html. Downloaded 16 December 1999.
196 Interviews with author: Senior CDC official (29 August 2000); former State Epidemiologist (18 August 2000);
Emergency Planner, Hospital Health Maintenance Organization (15 August 2000); Physician, Division of Disease Control,
Public Health Department (8 August 2000); Physician, Hospital Division of Emergency Medicine (31 May 2000). If staffing is
short, this approach would essentially mimic the military approach to mass casualty care, wherein a medic, a nurse, and an
orderly attend to as many as one hundred patients.
197 Hospitals in some regions are examining for the first time the utility of crisis relocation agreements between
hospitals to relieve the strain on area health care facilities. In the rare instances where hospital burden-sharing agreements exist,
they are being adjusted to accommodate the anticipated demands of a bioterrorist event. Interviews with author: Director,
Emergency Management Division, County Department of Public Safety (19 September 2000); Physician, Hospital Division of
Emergency Medicine (31 May 2000); Emergency Management Specialist, Office of Emergency Management (9 May 2000). On
the need for regional hospital planning: Senior CDC official (29 August 2000); former State Epidemiologist (18 August 2000).
264 Ataxia: The Chemical and Biological Terrorist Threat and the US Response
temporary field care centers.198 Other cities have standing arrangements to take over large indoor arenas and
stadiums in an emergency.199 Health care would also to be taken to the citizens in some cities, which plan
on setting up treatment centers in familiar locations, such as neighborhood fire stations, schools, local health
clinics, and heating/cooling centers used during temperature extremes. Mobile field care centers would also
be deployed. In these outposts, cross-disciplinary teams of EMTs, paramedics, nurses, physicians, and
mental health workers would conduct medical exams, dispense antibiotics and vaccines, and provide
counseling, as appropriate. Symptomatic patients would be sent to regular or field hospitals.200 This strategy
would be suitable for non-communicable diseases, but problematic if a contagious disease were in play. For
those circumstances, where it is key to keep person-to-person contact to a minimum, one city is planning to
commandeer fast food restaurants and administer drive-through prophylaxis.201
Monumental planning and logistical arrangements must be in place to make such plans work.
Personnel, medications, and equipment would need to be brought to the medical outposts in a timely fashion
and sustained until the crisis subsides. Accomplishing this feat would be difficult, because the hospitals
themselves expect to experience resource deficits of all types. All on-call personnel would be paged, but
198 One city is surveying the suitability of over 270 buildings for this purpose and plans to store the requisite support
equipment at these locations, such that during a crisis, medical staff could arrive, flip on the lights, and begin seeing patients.
Other cities have identified locations near hospitals where field hospitals can be erected. Interviews with author: Director,
Emergency Services Department (18 May 2000); Physician/EMS Medical Director (13 November 1999); Project Manager,
Emergency Management Planning (27 July 1999).
199 The advantage of using these sites is that there are existing systems, with which many citizens are already familiar,
to channel large crowds to and from such places. Interviews with author: Paramedic (12 May 2000); Emergency Management
Specialist, Office of Emergency Management (9 May 2000); Toxicologist (9 March 1999).
200 Ambulances would be stationed at the outposts to take those needing advanced medical care to hospitals. Interviews
with author: Physician/University Hospital Department of Emergency Medicine (20 September 2000); Fire EMS Statistician (30
August 2000); Physician, Division of Disease Control, Public Health Department (8 August 2000); Director, Emergency Services
Department (18 May 2000); Emergency Management Specialist, Office of Emergency Management (9 May 2000); Registered
Nurse/Chief, EMS Division, State Department of Public Health (3 February 2000); Physician/EMS Medical Director (13
November 1999); Project Manager, Emergency Management Planning (27 July 1999); Police Commander and Police Captain,
Special Operations Division (23 March 1999); Police Lieutenant (23 March 1999). Cautioning against medical outposts at fire
stations because traffic jams there would inhibit the ability to respond to fire emergencies: Physician/Director of Health, Public
Health Department (20 September 2000).
201 Turn-of-the-century quarantine law prohibited gatherings of more then ten people-even at funerals-to limit
opportunities for transmission. Whereas directing citizens to fire stations or sporting arenas would result in crowds at such
locations, having them remain in their cars for inoculations and/or receipt of pills would be in keeping with at-home isolation,
restricting interpersonal contact to the bare minimum. Moreover, everyone knows the location of neighborhood hamburger chain
restaurants. Pharmacies with drive-through windows may also be employed in this capacity. Interview with author:
Physician/Director of Health, Public Health Department (20 September 2000). Note that some hospitals already have drive-by
influenza shot programs, but the idea is to provide medication to the asymptomatic away from the hospitals.
Chapter 6 Metropolis, USA: Progress, Pitfalls in Front-line Readiness 265
there are indications that even medical professionals could be unsettled by the situation and shun work. One
physician made a prediction seconded by others: "One-half of the staff will run for the hills."202
Ignorance of such basic facts as the low contamination risks of most agents and the adequacy of
standard precautions, as noted in table 6.2, is still fairly widespread in the medical community. Otherwise,
hospital staffs would not have reacted as inappropriately as they have to mere anthrax hoaxes. One major
university teaching hospital refused to receive a possible anthrax patient, even after being assured by the
hazmat chief and the local health commissioner that the individual had been thoroughly decontaminated and
they were 99 percent certain that the substance involved was not anthrax.203 In another hospital emergency
department notified of incoming patients who might have been exposed to anthrax, the relevant antibiotics
(e.g., ciprofloxacin, doxycycline) disappeared from the shelves before the patients arrived.204 These
anecdotes accent the need for education to fortify the medical community's ability to care for this type of
patient, beginning with the basics. From the aforementioned 1998 survey of those involved in emergency
medicine residency programs, a worrisome number-64.5 percent-assessed their ability to clinically
manage casualties from a bioterrorist attack as less than adequate or very poor.205 One city is fighting the
possible exodus of hospital staff by ensuring that all of its hospitals stock enough antibiotics to treat medical
personnel.206
To fill out their rosters, hospitals would all probably call on the same temporary service companies
that provide nurses and other personnel to substitute for vacationing or ill staff.207 Severe nursing shortages
were expected everywhere. One city's officials are considering assigning EMTs to hospitals for routine
medical care, freeing up regular staff to work with critical cases and in the ICU. EMTs from prisons and coal
202 Interview with author: Physician/Director of Hospital Disaster EMS (27 July 1999). Also in agreement: Physician,
Division of Disease Control, Public Health Department (8 August 2000); Physician/Associate Medical Director, Fire EMS
Division (27 July 1999); Physician, Hospital Department of Emergency Medicine (24 March 1999); Physician/Associate
Director, Hospital Department of Emergency Medicine (9 March 1999).
203 Interview with author: District Fire Chief, EMS Division (2 March 2000).
204 Interview with author: former EMS Supervisor/Paramedic (12 July 2000). In a similar report, hospital personnel in
Indianapolis apparently gave themselves ciprofloxacin after an anthrax hoax at a local Planned Parenthood clinic in October
1998. Thirty-one clinic staffers were decontaminated both at the scene and at the hospital. Hospital staff also removed extra
supplies of the antibiotic from the hospital pharmacy. Melissa Hendricks, "Rx Against Terror,"Johns Hopkins Magazine
(February 1999). Internet: www.jhu.edu/~jhumag/0299web/germ.html. Downloaded 21 September 2000. On the panic of 250
hospital workers because of the presence a patient with meningococcal meningitis, which is not very contagious, see Osterholm
and Schwartz, Living Terrors, 4.
205 Pesik, Keim, Sampson, "Emergency Medicine Residency Program Training for Bioterrorism,"175.
206 Interview with author: Physician/University Hospital Department of Emergency Medicine (20 September 2000).
207 Interviews with author: Physician/EMS Medical Director (13 November 1999); Project Manager, Emergency
Management Planning (27 July 1999); Project Manager, Emergency Management Planning, Office of Emergency Management
(27 July 1999).
266 Ataxia: The Chemical and Biological Terrorist Threat and the US Response
mines may also be drafted for hospital service.208 Cities would probably call for federal help with manpower
at the same time that they request the national drug stockpile. Federal officials contend that vanguard assets,
such as Disaster Medical Assistance Teams, could be there within twelve to twenty-four hours. The quickest
transportation mode-commercial flights, Pentagon aircraft, trains, or buses-would be used.209 Local
concerns about working with relief assets from outside the region are discussed in box 6.4. The local
officials who have deployed with such teams counter that cities would probably be on their own for twenty-
four to seventy-two hours, and that the quantity of medical manpower that could arrive even in that
timeframe might fall far short of what would be needed.210
To illustrate the dilemma, the mid-May 2000 Topoff drill featured a hypothetical terrorist release
of plague in Denver, after which health care officials quickly found their medical facilities sinking under the
patient load and concluded that two thousand more medical personnel were needed on the ground within a
day to prevent the flight of citizens that would have further spread the disease.211 Getting that number of
physicians and nurses to a city and into hospitals and field treatment posts would be a tremendous logistic
achievement. Quite frankly, there have been no large-scale dress rehearsals to confirm whether civilian or
military medical assets could muster that many, that quickly, or even over a few days. Even so, the two
thousand figure seems almost quaint when compared to one US city's rough estimate that 45,000 health care
providers would be required to screen and treat its denizens, a great many of whom would have to be
imported.212 If a contagious disease were on the loose, finding local medical personnel to staff the medical
208 Interview with author: Registered Nurse/Chief, EMS Division, State Department of Public Health (3 February
2000).
209 Interview with author: Commander, US Public Health Service (3 July 2000). Disaster Medical Assistance Teams
consist of roughly thirty-five medical and additional support staff who deploy within twelve to twenty-four hours of notification
with medical and logistical supplies to make them self-sufficient for one to three days. Paul B. Roth and John K. Gaffney, "The
Federal Response Plan and Disaster Medical Assistance Teams in Domestic Disasters," Disaster Medicine 14, no. 2 (May 1996):
37182. Four National Medical Response Teams, which are specialized to handle nuclear, chemical, and biological casualties
are also available.
210 Interviews with author: Fire EMS Statistician (30 August 2000); Senior CDC official (29 August 2000); former
State Epidemiologist (18 August 2000); Physician, Division of Disease Control, Public Health Department (8 August 2000);
Director of Hospital EMS and Disaster Medicine (19 April 1999); EMS Superintendent-in-Chief (24 March 1999); Police
Lieutenant (23 March 1999); Physician, Hospital Department of Emergency Medicine (24 March 1999).
211 Interviews with author: Senior CDC Official (29 August 2000); Toxicologist (9 June 2000); Senior Official, HHS
Department (6 May 2000). During the drill, one medical outpost was opened and could handle 140 people per hour. As one of
the participants in the drill recounted, "For a city of 1 million, that's pitiful." As quoted in, Inglesby, Grossman, and O'Toole, "A
Plague on Your City: Observations from TOPOFF."
212 Interviews with author: Senior Official, HHS Department (6 May 2000); Project Manager, Emergency Management
Planning, Office of Emergency Management (27 July 1999).
Chapter 6 Metropolis, USA: Progress, Pitfalls in Front-line Readiness 267
outposts would be a significant obstacle.213 Local officials are searching for provisional staffing options until
federal help arrives. Some plans put city and federal health clinic personnel on field duty, while others are
looking to EMS and Red Cross personnel and drawing upon the local reservoir of suburban private practice
and retired doctors and nurses.214 Another idea, discussed in the Pentagon's Biological Weapons Improved
Response Program, entails drafting dentists, veterinarians, final-year medical school students, and nursing
students as "extenders" to fill out the ranks of health care givers.215 Of the probable nurse and doctor
shortage, one public health director noted that neither is needed to hand out pills, as long as who ever does
so is working under the supervision of medical professionals.216
Through the media, city officials hope to get the public's cooperation in keeping crowds at the
hospitals and neighborhood treatment centers to a manageable size. Announcements would be made about
when citizens should stay home, what symptoms they should watch for, how to treat oneself, and where to
go in neighborhoods for screening and prophylaxis.217 By no means, however, are cities counting on the
public to remain calm. Once an attack becomes public knowledge, a city's health care system would be
under siege and the demand for medications would skyrocket. At a certain stage, particularly if the public
does not have confidence that the crisis was being well-managed, citizens could mob private clinics,
pharmacies, and even veterinarians to get antibiotics and medical attention. Cities plan to assign police
213 Interviews with author: Director, Emergency Services Department (18 May 2000); Paramedic (12 May 2000);
Registered Nurse/Emergency Planner, Public Health Department (7 April 2000); Registered Nurse/Chief, EMS Division, State
Department of Public Health (3 February 2000); Physician/EMS Medical Director (13 November 1999); Project Manager,
Emergency Management Planning, Office of Emergency Management (27 July 1999); Physician, Hospital Department of
Emergency Medicine (24 March 1999). See also, Bartlett, "Applying Lessons Learned from Anthrax Case History to Other
Scenarios," 562.
214 Red Cross personnel can conduct health checkups, but are not authorized to give medical treatment. Interviews with
author: Physician/University Hospital Department of Emergency Medicine (20 September 2000); Fire EMS Statistician (30
August 2000); Emergency Planner, Hospital Health Maintenance Organization (15 August 2000); Physician, Division of Disease
Control, Public Health Department (8 August 2000); Commander, US Public Health Service (3 July 2000); Director, Emergency
Services Department (18 May 2000); Paramedic (12 May 2000); Registered Nurse/Emergency Planner, Public Health
Department (7 April 2000).
215 The report cautions that the medical and legal ramifications of drafting such individuals to help during the crisis
must be considered beforehand. This report lays out a template for medical surveillance, medical diagnosis, epidemiological
investigation, criminal investigation, mass prophylaxis, residual hazard assessment and mitigation, isolation and quarantine,
fatality management, and various logistic and recovery tasks. Interim Planning Guide: Improving Local and State Agency
Response to Terrorist Incidents Involving Biological Weapons, Biological Weapons Improved Response Program (Aberdeen,
Md.: US Army Soldier and Biological Chemical Command, 1 August 2000), 16. On plans to employ medical students:
Physician/University Hospital Department of Emergency Medicine (20 September 2000).
216 Interview with author: Physician/Director of Health, Public Health Department (20 September 2000).
217 Interviews with author: Physician, Division of Disease Control, Public Health Department (8 August 2000);
Physician, Hospital Division of Emergency Medicine (31 May 2000); Director, Emergency Services Department (18 May 2000);
Physician/EMS Medical Director (13 November 1999); Toxicologist (9 March 1999).
268 Ataxia: The Chemical and Biological Terrorist Threat and the US Response
security details to such sites and the medical outposts. Locals said they would also turn to the National
Guard for help with public order and security.218
The Bane of Bioterrorism Response Planning
Even in cities where emergency response planners have sketched a framework for a medical response
to a bioterrorist attack, one set of issues baffles them. Conceivably, the release of a communicable disease
could compel emergency and public health officials to enact serious measures to prevent its spread, including
the isolation of people and the quarantine of buildings and even entire sections of a city. These phrases are
the bane of emergency planning because in this day and age, it is unimaginably difficult to orchestrate and
control the movement of people. The ease of modern transportation and the likelihood that an outbreak may
not be detected for several days has led some to question whether quarantine and isolation-the traditional
methods for breaking the chain of a communicable disease-continue to be workable propositions. To most
Americans, a quarantine is an artifact, something their grandparents did in the days before vaccines
conquered polio, measles, and smallpox.
One of the things that would make instituting a quarantine so difficult is that in most states the
statutes governing the imposition of such restrictions are overlapping, somewhat contradictory, and
outdated. Beginning in the eighteenth century, state legislatures enacted layer upon layer of laws with
different structures and procedures for detecting, controlling, and preventing disease, each tailored to impact
the affliction sweeping the country at the time. A trio of legal scholars who surveyed the statutes in all fifty
states concluded that "[t]hese laws often do not reflect contemporary scientific understandings of disease,
current treatments of choice, or constitutional limits on states' authority to restrict individual liberties."219
This late 1990s survey found only a few states (e.g., Minnesota, Texas) where the statutes had been
218 Interviews with author: Director, Emergency Services Department (18 May 2000); Paramedic (12 May 2000);
Emergency Management Specialist, Office of Emergency Management (9 May 2000); Emergency Preparedness Director, Office
of Emergency Services (9 February 1999). During the Topoff drill in mid-May 2000, Denver police and the National Guard told
exercise officials that they would be unable to enforce a home quarantine. See Inglesby, Grossman, and O'Toole, "A Plague on
Your City: Observations from TOPOFF."
219 Lawrence O. Gostin, Scott Burris, and Zita Lazzarini, "The Law and the Public's Health: A Study of Infectious
Disease Law in the United States," Columbia Law Review 99, no. 59 (1999): 106. According to this survey, most states have two
or even three types of communicable disease laws, namely those pertaining to traditional sexually transmitted diseases, those
aimed at prevailing diseases of the time (e.g., smallpox, yellow fever, cholera, tuberculosis, syphilis, poliomyelitis, influenza,
and, most recently, HIV/AIDS), and general statutes for such noncontroversial contagious diseases as measles and malaria. See
pages 1023, 108. See also, Kristin Choo, "A Plague in the Making: US Lacks Legal Structure to Fight Bioterrorism, Critics
Say," American Bar Association Journal (December 1999). Internet: www.abanet.org/journal/dec99/12nterr.html. Downloaded
12 March 2000.
Chapter 6 Metropolis, USA: Progress, Pitfalls in Front-line Readiness 269
harmonized to create a uniform legal basis for disease control.220 On 15 March 2000, Colorado also amended
its statutes to clarify roles and authority for the control of communicable diseases.221
Cities participating in the MMRS program are required to identify which local official(s) have the
legal authority to issue quarantine or isolation orders and state the area(s) of a potential quarantine. These
requirements have been met, but only in the most superficial manner. In several cases, the extent of the
"plan" states that the local public health officer would decide when and where to execute isolation and
quarantine orders. For the most part, cities were dusting off as points of reference quarantine laws that were
last used over seventy years ago, but beyond that local authorities had few clues about how to proceed.
Some considered it downright unfeasible.222
One senior public health official, who has seen any number of draconian steps taken in the name of
preserving public health, argued that quarantines have been done before and it should not be such an ordeal
to institute one in the future.223 However, according to both local officials and legal scholars, enforcing a
mass quarantine in this day and age would be an exercise fraught with difficulty. First of all, state
jurisdiction on public health matters is widely recognized, but in the face of a possible pandemic, some might
argue for a presidential declaration of martial law, which would be an unprecedented act. Almost certainly,
a clash would occur between public health and legal officials at the local, state, and national levels about the
measures necessary and the entity with jurisdiction to act. Among the matters that would complicate
220 Gostin, Burris, Lazzarini, "The Law and the Public's Health," 108.
221 An Act Concerning the Creation of the Governor's Expert Emergency Epidemic Response Committee, Col. Rev.
Stat. § HB00-1077 (2000). This law created an expert advisory committee to advise the governor, who was given authority to
commandeer medical supplies and quarantine areas. This committee met for the first time during the aforementioned mid-May
2000 federal exercise mocking a terrorist attack in Denver involving plague. Aside from the many other lessons that this exercise
imparted about the difficulty of forestalling a pandemic, it was clear that since this law transferred some authority for local public
health to the state level, more work was needed to integrate this committee into the existing decision making structure. Interviews
with author: Senior CDC official (29 August 2000); Toxicologist, Poison Control Center (9 June 2000). See also, Inglesby,
Grossman, and O'Toole, "A Plague on Your City: Observations from TOPOFF."
222 Among the legal issues that must be addressed is that current quarantine and isolation laws apply to individuals, not
groups. Also, there is uncertainty as to whether a quarantine would violate interstate commerce laws by restricting access into
and out of areas. Interviews with author: General Manager, Emergency Department (22 September 2000); Director, Emergency
Management Division, County Department of Public Safety (19 September 2000); former State Epidemiologist (18 August
2000); Emergency Planner, Hospital Health Maintenance Organization (15 August 2000); Physician, Division of Disease
Control, Public Health Department (8 August 2000); Commander, US Public Health Service (3 July 2000); Federal Official,
Office of Emergency Preparedness, HHS Department (28 June 2000); Commander, US Public Health Service (28 June 2000);
Medical Toxicologist/Poison Control Center Director (13 June 2000); Physician, Hospital Division of Emergency Medicine (31
May 2000); Paramedic (12 May 2000); Emergency Management Specialist, Office of Emergency Management (9 May
2000);Commander, Public Health Service (6 May 2000); Senior Official, HHS Department (6 May 2000); Registered
Nurse/Chief, EMS Division, State Department of Public Health (3 February 2000); Police Detective/Bomb Squad member (19
January 2000); Fire Captain/Assistant Emergency Management Coordinator (5 January 2000); Project Manager, Emergency
Management Planning (27 July 1999); Police Lieutenant (23 March 1999); Paramedic/Emergency Planner, Public Health
Department (4 February 1999); Registered Nurse/Hospital Disaster Coordinator (4 February 1999).
223 Interview with author: Senior CDC Official (29 August 2000).
270 Ataxia: The Chemical and Biological Terrorist Threat and the US Response
imposing a quarantine is that most state statutes apply to individuals, which makes their application to large
groups of people impractical. A possible conflict with interstate commerce law exists. Local officials were
concerned about the legality of severing all traffic to contain an epidemic, not to mention the uproar this
would cause in the business community. Other aspects of a quarantine that elicited lively debate included
the level of force necessary to enforce a quarantine and whether to prosecute violators of a quarantine order.
With all these policy matters and legal authorities up in the air, interviewees said that cities were far from
having operable plans in place.224
Not only were local officials uncertain about their statutory authority to proceed with a quarantine,
they believed that the public would probably not cooperate with compulsory orders to commandeer property,
restrict movement of people, or forcibly remove them to designated locations. Traditionally, governments
have counted upon the public to comply with public health orders on the basis that the good of the
community overrides the rights of the individual. These days, however, citizens get angry at forced
evacuations for such visible calamities as hurricanes, floods, and wildfires, not to mention a stay-at-home-
order for a microscopic killer that they may doubt is in their midst. Police also questioned whether their
colleagues would recognize the authority of the public health officer to declare a quarantine or would even
stick around to enforce the order.225 Finally, some wondered whether there were enough local and state
police to quarantine a large metropolitan area in the first place.226
224 Interviews with author: General Manager, Emergency Department (22 September 2000); Director, Emergency
Management Division, County Department of Public Safety (19 September 2000); Director, Emergency Management Division,
County Department of Public Safety (19 September 2000); former State Epidemiologist (18 August 2000); Emergency Planner,
Hospital Health Maintenance Organization (15 August 2000); Physician, Division of Disease Control, Public Health Department
(8 August 2000); Commander, US Public Health Service (3 July 2000); Federal Official, Office of Emergency Preparedness,
HHS Department (28 June 2000); Commander, US Public Health Service (28 June 2000); Medical Toxicologist/Poison Control
Center Director (13 June 2000); Physician, Hospital Division of Emergency Medicine (31 May 2000); Paramedic (12 May
2000); Emergency Management Specialist, Office of Emergency Management (9 May 2000); Commander, Public Health Service
(6 May 2000); Senior Official, HHS Department (6 May 2000); Registered Nurse/Chief, EMS Division, State Department of
Public Health (3 February 2000); Police Detective/Bomb Squad member (19 January 2000); Fire Captain/Assistant Emergency
Management Coordinator (5 January 2000); Project Manager, Emergency Management Planning (27 July 1999); Police
Lieutenant (23 March 1999); Paramedic/Emergency Planner, Public Health Department (4 February 1999); Registered
Nurse/Hospital Disaster Coordinator (4 February 1999). For a more thorough discussion, Terry P. O'Brien, "Legal Response to
a Bioterrorist Event," paper presented at the National Disaster Medical System 2000 Conference, 1 May 2000, Las Vegas,
Nevada; and Gostin, Burris, Lazzarini, "The Law and the Public's Health." See also, Inglesby, Grossman, and O'Toole, "A
Plague on Your City: Observations from TOPOFF."
225 "If police officers knew that a biological agent had been released, 99 percent of the cops would not be here. They
would grab their families and leave." Interview with author: Police Captain, Special Operations (8 February 1999). Also
expressing doubt at the reliability of police in these circumstances: Police Detective/Bomb Squad member (19 January 2000);
Fire Captain/Assistant Emergency Management Coordinator (5 January 2000). See also, O'Brien, "Legal Response to a
Bioterrorist Event," 467, 523, 578, 67. Commenting on the likelihood that citizens would not cooperate and the fact that
police only knew about the authority of the public health officer since his city had endured a quarantine after an anthrax hoax:
Police Lieutenant, Tactical Support Office (18 September 2000).
226 Recounting concern of one state's officials that all of the police in the entire state would be insufficient to
quarantine that state's largest city, in an interview with the author: Commander, US Public Health Service (28 June 2000).
Similar comments were made by: Police Lieutenant (23 March 1999).
Chapter 6 Metropolis, USA: Progress, Pitfalls in Front-line Readiness 271
Communications: The Common Problem in Any Disaster Response
A chemical or a biological terrorist attack would create a crescendo of activity among city emergency
personnel. In most US cities, this type of crisis would quickly overwhelm the capacity of local
communications systems, hindering response effectiveness. At the same time that public safety and health
care providers were struggling to reach each other, public officials would be trying to get information to
citizens about what had taken place, how local government was responding, and what, if anything, citizens
should do for their own well-being. The magnitude of the news story would make for an aggressive media
atmosphere. In short, city officials could find communications crumbling around them on every front.
Despite universal recognition among rescuers and health care providers that communications
problems are chronic in every sizable emergency, communications is one of the most neglected areas of
emergency response. As one veteran put it, "In every disaster we've ever had and in every exercise we've
ever done, there have always been communications problems."227 First responders project that in an
unconventional terrorist event, field communications channels are likely to be overloaded. Complicating the
situation, metropolitan fire, police, and sometimes EMS departments are on different response frequencies,
than rescue agencies from the county, nearby cities, and the state. While a city's emergency response
agencies could be linked together, establishing reliable links with outside rescue organizations could be
challenging.228 Noting that his city already had problems working large fires, a battalion fire chief predicted
that after an unconventional terrorist attack, communications would "at best be a nightmare."229 Some count
upon the telephone companies to be able to take up the slack in an emergency, but the fact that "all-circuits-
busy" messages are common during a regular work week and ubiquitous on holidays should disabuse that
notion.230
Such would probably be the conditions as city emergency response officials would try to reach off-
duty personnel in specialized rescue units, mutual aid partners, county agencies, state, and perhaps federal
emergency authorities. Some communications chores would be handed off to the city emergency operations
227 Interview with author: Chief of Response Division, State Department of Civil Emergency Management (13 April
1999). Even more directly expressed, "communications are woefully underdeveloped," said the Director of an Emergency
Services Department (18 May 2000). Another interviewee noted that communications are "the weak link in disaster medicine."
Interview with author: Medical Toxicologist/Poison Control Center Director (13 June 2000).
228 Note that when EMS is part of the fire department, they share the same communications channels. Interviews with
author: General Manager, Emergency Department (22 September 2000); Deputy Director, Office of Emergency Management (26
May 2000); Director, Emergency Services Department (18 May 2000); Paramedic (12 May 2000); District Fire Chief, EMS
Division (2 March 2000); Project Manager, Emergency Management Planning (27 July 1999); Project Manager, Emergency
Management Planning (27 July 1999).
229 Interview with author: Battalion Fire Chief (17 November 1999).
230 Interviews with author: Medical Toxicologist/Poison Control Center Director (13 June 2000); Senior Official, HHS
Department (6 May 2000). See also, Inglesby, Grossman, and O'Toole, "A Plague on Your City: Observations from TOPOFF."
272 Ataxia: The Chemical and Biological Terrorist Threat and the US Response
center, and some could be taken care of the old-fashioned way in the field, with runners between the response
agencies. Fire, police, and EMS could then call back down their own channels to relay the requisite
instructions.231 While this cumbersome set-up is workable, it also leaves a great deal to be desired.
Several cities have taken steps to improve their communications hardware, putting 800 megahertz
radios in field units.232 To ensure contact with special rescue units, some cities have given team members
alphanumeric pagers or 450 megahertz radios.233 One city even purchased encrypted cellular telephones to
preclude eavesdropping by the media, public, or terrorists.234 Other emergency responders noted, with some
envy, that such hardware improvements were years down the road.235
Until more effective equipment is in place, several cities planned to avoid a communications
breakdown by assigning an amateur radio operator to shadow every major field commander. These ham
operators would also be sent to hospitals and the city emergency operations center. In some cities, they are
trained in the incident command system. Experience has shown that their flexible communications gear can
free up radio frequencies, enable clearer command communications when channels are overloaded, and be
especially useful when mutual aid partners are activated. Ham operators have been so essential to one city's
emergency response capability that a public health official declared, "I don't know what we would do
without them."236 In other cities, the rescue agencies have stated concerns about operational security if ham
radio operators were by their side at such a sensitive time.237
231 One city has selected five locations within its boundaries to pre-position its emergency operations center in closer
proximity to the disaster scene, arranging with the local telephone company to install several hundred telephone lines within a
couple of hours after a crisis begins. Interviews with author: FBI Special Agent (12 May 1999). On using the emergency
operations center to help resolve communications shortcomings: Director, Emergency Services Department (18 May 2000);
District Fire Chief, EMS Division (2 March 2000); Project Manager, Emergency Management Planning (27 July 1999).
232 Interviews with author: Deputy Director, Office of Emergency Management (26 May 2000); Director, Emergency
Services Department (18 May 2000); Registered Nurse/Emergency Planner, Public Health Department (7 April 2000); EMS
System Analyst/Paramedic, State Department of Health and Social Services (25 January 2000); Battalion Fire Chief/Emergency
Services Administrator (15 November 1999); Chief of Response Division, State Department of Civil Emergency Management
(13 April 1999).
233 Interviews with author: Battalion Fire Chief/Emergency Services Administrator (15 November 1999); Chief of
Response Division, State Department of Civil Emergency Management (13 April 1999).
234 Interview with author: Deputy Coordinator, Fire Emergency Preparedness and Disaster Services (3 February 2000).
235 Interviews with author: Paramedic (12 May 2000); Battalion Fire Chief (17 November 1999).
236 Interview with author: Registered Nurse/Emergency Planner, Public Health Department (7 April 2000). Ham
operators work through two organizations, the Radio Amateur Civil Emergency Services (RACES) and ARIES. Interview with
author: Ham radio operator (8 February 1999). Others quick to praise ham radio operators: Paramedic (12 May 2000); Battalion
Fire Chief (17 November 1999); Emergency Preparedness Director, Office of Emergency Services (8 February 1999).
237 Interviews with author: Project Manager, Emergency Management Planning (27 July 1999); Ham radio operator (8
February 1999).
Chapter 6 Metropolis, USA: Progress, Pitfalls in Front-line Readiness 273
While field communications may be messy, they are even worse in the health care system. Hospitals
often lack the basic equipment to communicate effectively with field units, each other, health departments,
and laboratories. To illustrate the point, one state's public health department requires hospitals to report their
bed status every four hours if they go on bypass, anticipating that such reports would be filed via the Internet.
However, most of the hospital emergency departments did not even have Internet access and therefore filed
reports via facsimile, flooding the fax machine in the state department of health.238 Staff doctors carry
pagers, but caring for a massive number of chemical or biological casualties, plus patients already in
hospitals, could tax hospital workers in short order. If emergency officials needed to reach all area doctors,
the only alternative for most cities would be to issue a press release.239 Using the media to ask doctors to
volunteer to treat patients with infectious disease "X" before a public announcement of the health crisis has
been made has obvious drawbacks.
Sporadically, cities have tried to improve emergency communications with hospitals and public
health departments. One city, for instance, linked the hospitals in its metropolitan areas via radio so that all
could be reached simultaneously.240 Recognizing that hospital communications are a weak link in the
emergency response system, the CDC began awarding grants to build health alert networks between local
hospitals and health departments. This grant program, as noted in chapter 4, is small in size. These grants
are not aimed at improving inter-hospital communications, which those in the health care community still
view as essential to a sound disaster response.241
If citizens do not happen to be television watchers or radio listeners, city emergency officials must
be ready to reach them quickly and directly.242 Police could go door-to-door, informing people of the need
238 Interview with author: Registered Nurse/Chief, EMS Division, State Department of Public Health (3 February
2000). Hospital communications are equally weak elsewhere. Interviews with author: Physician, Hospital Division of
Emergency Medicine (31 May 2000); Registered Nurse/Hospital Disaster Coordinator (4 February 1999). See also, Victoria
Garshnek and Frederick M. Burkle, Jr., "Telecommunications Systems in Support of Disaster Medicine: Applications of Basic
Information Pathways," Annals of Emergency Medicine 34, no. 2 (August 1999): 2138; Inglesby, Grossman, and O'Toole, "A
Plague on Your City: Observations from TOPOFF."
239 Interview with author: Physician/EMS Medical Director (12 May 1999). See also, Bartlett, "Applying Lessons
Learned from Anthrax Case History to Other Scenarios," 562.
240 Interview with author: EMS Superintendent-in-Chief (24 March 1999).
241 Interviews with author: Registered Nurse/Chief, EMS Division, State Department of Public Health (3 February
2000); Deputy Coordinator, Fire Emergency Preparedness and Disaster Services (3 February 2000).
242 One city has arranged for an alert to be broadcast over the National Weather Service system. Interview with author:
Project Manager, Emergency Management Planning, Office of Emergency Management (27 July 1999). The urgency of
providing information to the public, immediately and continuously, to help cut down on panic and chaos was one of three lessons
that Swedish doctors drew from studying the experience of the Bhopal chemical accident. They also emphasized the importance
of training rescuers in chemical casualty care and setting up satellite health care facilities so that hospitals would not be overrun.
H.G. Lorin and P.E.J. Kulling, "The Bhopal Tragedy-What Has Swedish Disaster Medicine Planning Learned From It?"
Journal of Emergency Medicine 4, (1986): 3116.
274 Ataxia: The Chemical and Biological Terrorist Threat and the US Response
to evacuate or of special precautions they should take. Information could also be announced from the public
address systems on patrol cars, an operation that must be done properly in order to be effective.243 In urgent
situations where police are already stretched thin, door-to-door knocking or public address system caravans
may not be prudent. Software systems are available that can dial all of the listed numbers within a
geographic area to deliver emergency messages to the public. A city's emergency operations center could
activate a direct-call alert system to instruct citizens to stay indoors and seal their homes, sheltering-in-place
until a toxic cloud leaves the area. Or, citizens could be told where to go for medical check-ups,
vaccinations, and antibiotics. The message delivered could refer citizens to a central number for additional
taped instructions or updates about the situation.244
A chemical or biological terrorist attack would generate staggering media interest. When it comes
to tragedies, scandals, and celebrities, the press has often gone overboard, but in the late 1990s they also
abandoned bedrock rules of journalism (e.g., confirmation from two independent sources) in favor of citing
other news reports.245 At a one-day symposium on the topic of press coverage of an unconventional terrorist
event attended by some of the country's most prestigious media outlets, the consensus among press
representatives was that if a bioterrorist attack occurred in their city, there would be absolutely no holds
barred to get the story. If local public health authorities did not promptly volunteer information about the
disease concerned and the circumstances of its presence in the city, they noted, the atmosphere between the
media and city officials would become very combative and distrustful. Moreover, members of the media said
they would not hesitate to pursue any independent leads that such an event was in the offing, stalking hospital
wards or any other location that might yield an angle on the story. "The minute I got a whiff that there was
an anthrax case in the hospital, I would consider that a huge story." Continued the producer of a major
newscast, "If that case was the result of a possible bioterrorist attack, it would be even bigger news. I would
be all anthrax, all the time."246 In other words, the distinction between yellow and white journalism would
243 If the car is driven at a slow constant speed, the message cannot be clearly heard by those inside their homes.
Instead, police need to stop the car in the middle of the block while the message is delivered in its entirety, before moving on to
the next stop. Interview with author: Police Lieutenant (23 March 1999).
244 Interviews with author: Director, Emergency Management Division, County Department of Public Safety (19
September 2000); Paramedic Operations Supervisor (9 March 1999); Emergency Planner, Office of Emergency Management (8
March 1999). Also, Timothy Shenk, "Don't Call Us, We'll Call You; Reverse 911 Technology Allows Emergency Personnel To
Issue Mass Telephone Warnings," Daily News-Record [Harrisonburg, Va.], 26 June 2000; Jody Benjamin, "This Police
Department Will Make the 911 Calls," Sun-Sentinel [Ft. Lauderdale, Fla.], 19 January 1997. Reverse 911 from Sigma/Micro
Corporation is one of the services that provides this capability. Utilizing Geographical Information Systems computer mapping
capabilities and a phone number database, the $50,000 system enables emergency personnel to disseminate information to a
specific population, determined either geographically or via identification as an interested group (e.g., businesses, crimewatch
members) within the database. For further details, see the company's website: http://www.r911.com.
245 For example, wretched excess characterized the media's coverage of the O.J. Simpson trial, the deaths of Princess
Diana and John F. Kennedy, Jr., and the Monica Lewinsky scandal.
246 Quote from producer of a major news broadcast. This symposium was attended by the author, as well as subject
experts and reporters, medical and science writers, editors, and producers. Among the outlets present were CBS television and
radio, CNN, New York Times, New York Post, Newsday, and ABC's "Nightline." "Reporting on Weapons of Mass Destruction:
Chapter 6 Metropolis, USA: Progress, Pitfalls in Front-line Readiness 275
disappear in a nanosecond. The local media would give the story blanket coverage, as would national and
international press outlets. Press accounts would be suffocating, but not necessarily accurate or helpful.247
Rescue agencies, mayor's offices, and hospitals recognized long ago the need to be pro-active with
the media. These organizations all have public affairs officers, and the potential for lack of coordination
among them is great. Each would hold press conferences with the mutual objective of getting helpful
information and instructions to the public, but each organization would also have slightly different objectives
in mind. For example, from the perspective of the field response agencies, the designated spokesperson's
task is to "feed the animals and keep them away" from the disaster scene so that rescuers can go about their
jobs.248 Moreover, every agency would also want to show their organization's actions in the best possible
light. "Spinning" competitions between different response agencies surfaced in chemical and bioterrorism
response drills, and locals predicted that oneupsmanship and confusing information would be even greater
during an actual event.249 Sometimes the competition would be intentional, other times inadvertent. Either
way, once a garbled message got to the public, the damage would be done. One official recounted botched
communications after a flood, when three different public health officials gave contradictory instructions to
boil water for two, five, and twenty minutes. Later, when public health officials asked people to report for
shots as a precaution against cholera, citizens balked, lacking confidence that health officials knew what they
were doing.250
With so many different press spokesmen at work, media coverage could easily become incoherent.
A number of cities have begun to lay the groundwork for better press relations, briefing reporters on the
problem, inviting them to observe or participate in unconventional terrorism response drills, and even
Responsibility, Reliability & Readiness," Fred Friendly Seminars Inc. and International Advisory Group, 26 July 1999, New
York, New York. Note that press requests for immediate disclosure contradict the argument that, given the need to take all
possible steps to encourage public calm, the announcement of a bioterrorist attack should come from the president of the country
or the afflicted state's governor, flanked by authorities that Americans know and trust on public health matters (e.g., former
Surgeon General C. Everett Koop). This recommendation was made both at the seminar and in an interview with author: Senior
Official, HHS Department (6 May 2000).
247 On the aggressiveness of reporters during disasters, in an interview with the author: Chief of Response Division,
State Department of Civil Emergency Management (13 April 1999).
248 Interview with author: Deputy Coordinator, Fire Emergency Preparedness and Disaster Services (3 February 2000).
249 In one of the three cities where the Topoff drill was staged in mid-May 2000, the FBI tried to take control of media
relations early in the exercise, but was challenged by federal public health officials who believed that they were the proper
authorities to impart public health and safety messages. Local officials were pushed to the side by the federal agencies
concerned. Interview with author: former EMS Supervisor/Paramedic (12 July 2000). During one city's biological tabletop
exercise, the participating agencies attempted to game relations with the media, but could not agree on a lead media agency or the
messages to be communicated. Interview with author: Registered Nurse/Chief, EMS Division, State Department of Public Health
(3 February 2000).
250 Interview with author: Senior Official, HHS Department (6 May 2000).
276 Ataxia: The Chemical and Biological Terrorist Threat and the US Response
including them in disaster response planning.251 One city's fire department holds a one-day training camp
for press representatives, a strategy that allows rescuers to get a handle on press activities because the local
media must designate on-scene and emergency operations center reporters.252 Still, among those in the
emergency response community, the creation and implementation of a comprehensive media strategy was
recognized as a "glaring deficiency."253 Unless hardware and interpersonal communications problems are
fixed, local, state, and federal officials would end up giving a disjointed message to the public at the very
time it would be essential to provide the most cohesive message possible.
251 Interviews with author: Fire EMS Statistician (30 August 2000); Physician, Hospital Division of Emergency
Medicine (31 May 2000); Paramedic (12 May 2000); MMRS Coordinator, Fire Department (9 May 2000); District Fire Chief,
EMS Division (2 March 2000); Detective/Bomb Squad (19 January 2000); Captain/Assistant Emergency Management
Coordinator (5 January 2000); Battalion Fire Chief (15 November 1999); Physician/EMS Medical Director (13 November 1999);
Assistant Director, Office of Emergency Management (23 March 1999); Emergency Preparedness Director, Office of Emergency
Services (9 February 1999); Director, Office of Emergency Services (4 February 1999).
252 Local media outlets are allowed to send one reporter apiece to the scene and the emergency operations center, which
cuts down on the number of reporters facing rescuers and emergency managers. The one-day boot camp also ensures that the
reporters know the basics of fire, hazmat, rescue operations, and unconventional terrorism response. Interview with author: Fire
EMS Statistician (30 August 2000).
253 Interview with author: Police Detective/Bomb Squad member (19 January 2000). Also on this point: Medical
Toxicologist/Poison Control Center Director (13 June 2000); Physician, Hospital Division of Emergency Medicine (31 May
2000); Director, Emergency Services Department (18 May 2000); Director of an Emergency Services Department (18 May
2000); Registered Nurse/Chief, EMS Division, State Department of Public Health (3 February 2000); Chief of Response
Division, State Department of Civil Emergency Management (13 April 1999); EMS Superintendent-in-Chief (24 March 1999);
Registered Nurse/Hospital Disaster Coordinator (4 February 1999). See also, Garshnek and Burkle, Jr., "Telecommunications
Systems in Support of Disaster Medicine," 213-8.