Plan "D"

Plan "D" is a plan for hospital integration with the community, for the purposes of emergency preparedness. According to PlanD, one or more hospitals work in concert with the community, and, in particular, with facility owners, in order to plan an orderly transport of patients from their facility to the one or more participating hospitals.

Plan D involves two main elements:

  1. an established protocol of egress from a potential site of a disaster, in which the egress protocol includes at least a minimal contamination reduction of victims during or prior to their egress;
  2. an electronic communications protocol between a participating facility and a participating hospital.

Firstly, it is suggested that managers of particpating shopping concourses, train stations, airport terminals, and other places where people gather (places where people come together are generally called "concourses") designate a specific location as a casualty collection point (CCP).

In a large building, for example, a certain specific floor could be designated as the CCP.

Secondly, In a fully implemented scenario, special Push Stations would take the form of a panic button, similar to, but distinct from a fire alarm Pull Station, with the same sorts of penalties for misuse such as false alarm. PlanD would eventually include Decon Drills, similar to fire drills, in which instead of everyone running out of the building, everyone would stay inside, and move to a decontamination and/or casualty collection point in an orderly fashion.

Upon activating a Push Station, the doors to the building lock, to prevent anyone from outside coming into the building and being infected, as well as to ensure that persons in the building exit only through the specially designated decontamination concourse ("D-concourse"). This door locking functionality is possible because many large concourses already have magnetic door locks, or similar doors already designated as "Emergency Exit Unlocked by Fire Alarm". Therefore a Decon Alarm should be connected to the fire alarm, so that it can also control the entrances and exits that are so-equipped.

The Decon Alarm would be activated by any of the Push Stations, and should sound audible alarms throughout the building. The sound should be distinct from fire alarms, and a suitable sound would be a repeating down-chirp (Decending-pitch tone for Decon).

Eventually, as PlanD becomes adopted by equipment manufacturers, other devices such as elevators and escalators would become PlanD compliant. A PlanD compliant elevator, for example, might have special firmware in the control system that would receive input from the Push Stations, so that during an alarm condition, the elevators would reprogram themselves to optimally transport people to a special floor, say, for example, "Floor D". The designation "D" is suitably distinct from most other elevator markings like numerals, or letters "M" (main floor), "B" (basement), "P1" "P2", etc. (parking). Similarly, some of the escalators in a shopping concourse, could change direction, so that all of the escalators carry people in the same direction, toward "Floor D" or the "D-concourse".

Initial processing of victims at a D-concourse

Deconcourse is a casualty collection point, such as a designated floor of the building, or designated area of the building, where patients are collected for transport to hospital instead of having panic-stricken patients flee from the building and clog the parking lots with their personal vehicles (i.e. imagine if a victim gets into a car, is driving to hospital, and then starts having convulsions, causing his or her vehicle to swerve into oncoming traffic).

Fleeing patients would create mahem and disorder that would only slow down the arrival of ambulances. Instead, the Decon Alarm Panel, which is wired to one or more participating hospitals, signals an emergency and links in the participating facility's CCTV surveillance system to the hospital, so that emergency responders at the hospital can see what is happening and estimate the number of ambulances required to dispatch.

As soon as a Push Station is activated, help is already on the way. While victims are being collected in the Deconcourse, special ambulances are in-transit to the participating facility where the emergency has occurred.

The facility provides the best care that it can. If the facility has prepared any decon-plan, that plan is initiated. At a minimum, victims are separated by gender, and then disrobed in the Deconcourse, so that the potentially contaminated shoes, clothing, and personal effects of those with higher contamination levels do not spread contamination to other possibly less-contaminated individuals, or to others. Research has shown that in many terror attack exposure scenarios, merely disrobing removes 80 to 90% of the contamination. If the facility has fire sprinklers or other means for washing down the victims, that may also be considered (alternatively if the Deconcourse area is an area that has tiled walls, concrete floor, or the like, it may be practical to hose down the victims using in-building fire hoses, or the like).

However, it is estimated that typically the time required to move everyone to the Deconcourse, separate them by gender, and disrobe them, would be approximately equal to the time it takes the special ambulances to arrive from the hospital. In this case the victims are taken into the special ambulances which are themselves equipped to perform decontamination during transport.

The washbus concept

The washbus is a Triage+Treatment+Transport vehicle that integrates decontamination (decon is treatment) with patient transportation.

The basic idea is a Treatment vehicle that can seat a large number of ambulatory patients and decontaminate them while they are safely seated during transport.

It functions like an inverse carwash to save valuable time and lives, by putting transit time to practical use, so that contaminated ambulatory patients can be immediately admitted to hospital as soon as the vehicle arrives at the hospital.

Shoes, clothing, and other personal items are either left at a participating facility (assuming that dry decon, i.e. disrobing, has already been carried out at the participating facility), or the items are stored safely in the luggage compartment below the bus for retrieval at the hospital.

One or two washbuses (one with a tarp hanging down the middle, or separate washbuses for men and women) would work in parallel with the fixed decon facilities at the hospital, resulting in increased total throughput. A washbus might, for example, be stationed at an election, a political convention, or a similar likely terror target to ensure no delay (neither delay at the incident site nor delay at the hospital) occurs due to the need to decon patients before they are admitted to hospital, or washbuses may be stationed at strategic locations near areas that have a lot of likely terrorist targets (a lot of large shopping malls, subway stations, and the like).

Implementational details for washbus as "inverse carwash":

Usually only the exteriour of a vehicle can withstand getting wet, but a specially designed vehicle could feature inward-directed spray that comes from the vehicle itself.

The major problem with wetting down the inside of a bus would be the seats (upholstery) and the seat belts (if any) which are made of fabric.


Ambulatory victims participating in PlanD would be disrobed and ready to board one or more washbuses as soon as they arrived at the participating facility.

Alternatively, ambulatory victims would undress themselves, stow their shoes, clothing, and personal effects in the luggage compartment below the bus, and board the bus for a sit-down shower that would occur during transport. Men and women would undress on opposite sides of the bus (the bus would be equipped with under-bus storage compartments on both sides). One gender would board, and be restrained, a tarp would drop down in the middle of the bus to create a privacy barrier, and then the other gender would board. For privacy, the windows could be frosted either permanently or temporarily with foam spray on the outside that would last until the bus was loaded and out of the way of onlookers and the media.

The showers would be timed to dispense a limited but sufficient amount of decon solution at a rate that matches the length of the journey. If the nearest hospital were some larger distance away, the showers would run longer, but with a lesser flow-rate, alternating with dry-air-jet decon.

Human waste disposal

To avoid confusion and possible spread of contamination among a potentially hysterical busload of panicky victims, consider, perhaps, means for disposal of human waste being incorporated into the seating. For example, an elongated slot running the length of the seats could receive waste that would be fed to a collection tank in the bus, along with shower runoff, vomitus, drainage, etc. (infrastructure that might already need to exist for the showerbus).

Dry decon (airwash bus)

Even without the sit-down showers, simply having the victims disrobe and "air out" for the entire duration of their trip to the hospital may prove sufficient for removal of 90 percent of any possible contamination. Additonally, air jets or "air curtains" may be used to keep clean air running in from outside (and discharged by way of a HEPA filter), so that one contaminated victim does not contaminate others who are seated in close proximity.

Clean Air (Washplanes)

A similar configuration could be used in air traponsort of victims. However, due to weight constraints it may not be possible to carry large amounts of shower water onboard the special aircraft. In this case a large portion of decon could be by way of the "air out" method.

Washbus Quarantine+isolation

The bus may be divided into sections to separate quarantine and isolation, to some degree. One or more empty rows of seats may separate victims known to be contaminated to a greater degree than others (i.e. those with liquid chemical agent visibly present separated from those with vapor-only exposure). Additional dividers could be modular in design so that they could be attached to any of a large number of snap-in locations depending on specific circumstances. Properly designed vehicle restraint bars would prevent victims from wandering about the bus or attempting to flee. Restraint bars would be remotely operated (like in an amusement ride), so that everyone would be released automatically as soon as the bus was safely inside a properly secured casualty collection point. Alternatively, victim release could be timed or sequenced, e.g. ordered by gender, or by severity of exposure so that triage could be enforced so that there is not one sudden inrush of a full busload of patients running toward the hospital doors at the same time.

Hospital integration with subway systems

As an example of PlanD's urban integration with one or more hospitals, consider the participation of a hospital within the context of PlanD.

SubWash is a concept that addresses the question of how victims on, in, or around a subway system can be rushed to hospital in the event of an incident involving nuclear, biological, or chemical agents.

Consider, for example, a suspected or actual case of bird flu within a subway car. Upon alert, the subway goes immediately to a special decon station, let's say, for example, "Stop D". Decon stations are built at one or more abandoned subway stops, or at dual-use subway stops (stops that can be converted to SubWash stops). In the event of a dual-use stop, attendants at the SubWash stop are notified that a potentially contaminated train is on the way. The SubWash stop is rapidly evacuated and locked down, to prepare for the arrival of the train.

Subway stops are generally relatively secure from unwanted ingress, egress, or contamination. Usually there are stainless steel grilles that can block all entrances and exits. This means that when the stop is evacuated nobody can get in. When the train arrives with potentially contaminated individuals, none of them can get out of the SubWash stop, except as prescribed by the containment protocol.

Subway stops themselves are already generally very much like shower rooms in the sense that the walls are usually already covered in ceramic tiles, and all of the fixtures are usually waterproof. Usually the floors of of a non-slip material because of the high degree of foot traffic that normally carries rain and slush and snow into the subway stop, thus making it necessary to make the floors of material that has good traction when wet.

In one or more subway stops, special showers may be installed that are on standby (not used) unless there is an emergency of the type described above.

Alternatively, or additionally, subway stops are often connected to bus areas, and connect to bus lines, so that one or more washbuses may be parked at such a SubWash stop. In this way, victims released from an incoming train may exit into the bus loading area, since all the other exits would lock or be locked. Once safely loaded into the washbus or washbuses, the doors to the bus area may open up, allowing the bus to quickly take the victims to hospital and decontaminate them on the way.

If there is one person showing immediate symptoms that one person may be taken in a separate ambulance, while everyone else is moved to isolation, quarantine, or examined and released after decon, in order to prevent possible spread of droplets, particulate matter, or the like, from the contaminated area or other individual(s).

--S. Mann, DECONference 2002