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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program (2002)

Chapter: Appendix F Scenarios and Discussion Materials for Use on Site Visits

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Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
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F
Scenarios and Discussion Materials for Use on Site Visits

BIOLOGICAL SCENARIO (ANTHRAX)

Potential Participants

Fire department

Police department or sheriff’s office

Office of Emergency Services

Public works department

Public health department

Public information officer

General counsel’s office

Medical examiner or Coroner’s Office

Emergency department physician

Transportation authority (port authority, airport authority, etc.)

Coordinator of volunteer organizations

Emergency medical service

Hazardous materials team

State emergency management office

Area military and local federal facilities

National Guard

U.S. Department of Energy

Federal Bureau of Investigation

Public Health Service

Centers for Disease Control and Prevention

Environmental Protection Agency

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
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U.S. Coast Guard

Representatives of neighboring jurisdictions

The list is not intended to be either prescriptive or inclusive.

Instructor’s Background Information on the Incident, Scene I

This scenario involving terrorism with a biological weapon of mass destruction (WMD) portrays an incident that local response groups and agencies can use to evaluate their coordination and response capabilities. They may also identify shortfalls in personnel or other resources that can be supplemented by state or federal sources. The scenario is intended to portray only the hypothetical technical features of a biological terrorism incident and does not represent an actual event.

This scenario takes place in [city, state]. [Briefly describe the airport at which this incident occurs.] In this scenario, a terrorist obtains four aerosol containers (emitting particles 1 to 5 micrometers in diameter); each is filled with 25 grams of freeze-dried, genetically altered Bacillus anthracis (anthrax) spores. The aerosol containers are placed in air ducts near baggage claim and ticketing areas within the airport, but immediately after the placement of the containers a security guard comes upon the terrorists and is stabbed.

Anthrax spores are biological agents that enter the body through inhalation, the primary danger in this scenario. Exposure to anthrax spores can also occur via breaks in the skin (open wounds, sores, and even very minor scratches). B. anthracis is a persistent agent capable of surviving in spore form for 1 to 2 years in direct sunlight or for decades if it is protected from direct sunlight.

The effects after an exposure normally appear within 2 to 3 days, although new cases occurred up to 60 days after a now well-characterized aerosol emission in Sverdlosk, Russia, in 1979. The initial symptoms of exposure to anthrax spores are low-grade fever and aches and pains, resembling the early stages of the flu. The illness progresses over 2 to 3 days until the sudden development of severe respiratory distress, followed by shock and death within 24 to 36 hours in essentially all untreated cases. The rate of mortality is high even with intensive supportive therapy and antibiotics, especially if treatment is delayed after the victim first exhibits symptoms.

An easily observable event indicating the initial release of anthrax spores is not necessary, and most planning has assumed that bioterrorism involving anthrax would be a covert release that would result in the wide dispersal of victims, both geographically and, because of varying incubation times, temporally. The only experience to date, however, has been

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

with anthrax spore-contaminated letters in which the letters explicitly described their contents (in addition, hundreds of similar letters that falsely claimed to contain anthrax spores were also sent). In this scenario terrorists are nearly caught in the act, but it is not immediately clear that they are terrorists or that anthrax is involved. Indications of infection at its early stages can be confused with the symptoms that result from a wide variety of viral, bacterial, and fungal infections. Anthrax is therefore not immediately diagnosed.

Anthrax is difficult to detect through routine blood testing and culture when the agent is not suspected. Once a biological agent or anthrax is suspected, however, anthrax is easy to detect through more specific testing. There are several tests specifically for anthrax. Most of these require cultures, which can take 12 to 24 hours to produce results.

In this scenario it is not apparent at first that a biological agent was used. No terrorist organization called in a threat or claimed responsibility for the act. In fact, it is not until Scene II that terrorism emerges as the cause of this incident.

The medics responding to the stabbing in the airport do not suspect a terrorist attack and do not wear personal protective equipment. Anthrax spores contaminate the hospital where the initial victims are taken for treatment. People passing through the airport or coming into contact with any of these people are also potentially exposed. The [area] emergency medical services and police personnel responding to the stabbing are exposed as well.

Responders are challenged to

  • assess the incident,

  • initiate appropriate public health operations, and

  • arrange for fast medical treatment of victims.

At this time, the local and state health departments and the Centers for Disease Control and Prevention (CDC) are involved in the community health emergency (prompted by notification by doctors and hospitals in the scenario) and the Emergency Operations Center (EOC) is activated. Many command and control issues are raised because this is initially treated as a community health emergency. These issues should be explored in Session I. The integration of federal assets should be discussed briefly during Session I, but it should also be discussed in further detail during Sessions II and III. It is not readily apparent that this is a terrorism-related incident. Once this is determined, during Scene II, notification of the Federal Bureau of Investigation (FBI) is required. The facilitator should explore how this notification takes place.

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
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Scene I: The WMD Event Occurs

[City, state, of the incident in the scenario], [day of week, date of the incident in the scenario]. The weather forecast predicts [insert the weather forecast for the scenario within the normal range for the date of the exercise; include the daily temperature range, the amount of cloud cover, and the wind speed and direction; if possible, set up the scenario for a calm, cool, overcast day]. At midday it is [temperature, in degrees Fahrenheit, within the forecasted range].

On [date of the exercise or the incident in the scenario], at approximately 8 a.m. (0800 hours), a security guard at the airport confronts two men in coveralls exiting a restricted portion of the baggage claim area and is stabbed by one of the men. The men then flee into the crowd. The guard manages to call airport security before he loses consciousness. Police respond to the scene and call an ambulance. Paramedics arrive within 6 minutes and begin treating the security guard. Police try to locate passengers who may have seen the fleeing men.

By 5 p.m. (1700 hours) on [day, date of the 3rd day of the scenario], a number of airport workers at [name of airport] have reported to the occupational health clinic complaining of flulike symptoms. Throughout the following day, more and more workers complain of similar symptoms. The number of workers calling in sick or leaving work early due to illness increases dramatically. Affected workers visit numerous local doctors and hospitals.

By 3 p.m. (1500 hours) [day, date of the 4th day of the scenario], more than[number equal to approximately 35 percent of the total number of airport personnel] airport personnel call in sick, complaining of malaise, low-grade fever, and chest pains. The number of illnesses causes concern among airport operators about the ability of the remaining personnel to continue normal operations. The airport personnel office notes that many of the ill employees work in and around the ticketing and baggage claim areas. Doctors and hospitals notify the local health department, prompted by indications that the illness is reaching epidemic proportions. The state health department and the CDC in Atlanta, Georgia, are also notified.

The local news media picks up the story and broadcasts it locally. Other major cities across the nation, especially [names of two of the major destinations from airport], report scattered incidents of similar illnesses. Approximately half of the students and faculty at a school adjacent to the airport are also ill with flulike symptoms. Some visit local doctors and hospitals.

By [day, date of the 5th day of the scenario] at 9 a.m. (0900 hours), local hospitals report that approximately 30 airport workers are dead or critically ill; these deaths are reported to the [name of state health department] and the CDC. Another 2,000 individuals (former passengers) demonstrate

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

flulike symptoms and visit doctors and hospitals throughout the metropolitan area; several have died. These illnesses are also reported to the [name of state health department] and the CDC. The CDC deploys an epidemiological research team to [location of incident] to assist the local and state health authorities as they continue their investigation and analysis.

The State Health Department notifies the [name of state] Emergency Management Agency (EMA) of the unfolding situation. The [name of state] EMA, in turn, notifies the regional office of the Federal Emergency Management Agency (FEMA) and the FBI. The Regional Operations Center (ROC), situated in [location of ROC], is activated.

The CDC investigation centers on the airport because it is a common denominator among the illnesses and deaths. Because of the number of sick and dead victims, the CDC and state health authorities recommend that the city shut down the airport until the site is thoroughly evaluated for health risks. The airport is shut down completely; outgoing flights are canceled and incoming flights are diverted to other regional airports. Health department personnel attempt to develop a strategy to track passengers and contact the families of passengers who may be infected; the CDC recommends that response personnel track all passengers who have passed through airport facilities in the past week. All personnel entering the airport after the shutdown order are issued biohazard protective gear that they must wear. Specimens are collected from hundreds of surfaces at the airport and sent to [names of two nearest major hospitals or medical centers].

Shortly after 10 a.m. (1000 hours) on [day, date of the 6th day of the scenario], epidemiological investigation reports released by the CDC suggest that a biological weapons agent may be the cause of the rash of illnesses and deaths.

By midday, the incident gains national media attention. The public inundates the airport and local hospitals with phone calls concerning potential contamination.

Reporters request information regarding the shutdown of the airport, its surrounding area, and the city’s response to the incident. A major national cable news network requests an interview with a representative from the city. A Joint Information Center is established in the ROC to ensure that the CDC and state and local health departments as well as the FBI and state and local law enforcement agencies deliver accurate and consistent messages.

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

Facilitated Discussion

Purpose

This guided group discussion is designed to help participants understand the types of issues that they will encounter and the conflicts across agencies and jurisdictions that can occur in coordinating, communicating, and responding to such an incident. It also gives participants an opportunity to assess their jurisdiction’s ability to respond to such an incident.

Presentation

Guide a group discussion by asking the numbered questions on the following pages. These questions are not all inclusive; use them to develop additional questions, as necessary. Some additional questions are included should there be a need to stimulate further discussion.

Don’t forget that good facilitators speak much less than the participants. This is an assessment activity, not a formal instructional class.

Provide participants with a copy of the questions that does not include the answers to questions, additional questions, or the final note to the facilitator.

Be sure to touch on the following areas: direction and control, notification and activation, communications, warning and emergency public information, hazard assessment, and management of field response.

Questions, Scene I

1. How will you learn of this incident involving a WMD? What internal and external notifications should you make? Are you satisfied that the current notification process is timely and adequate? How does the delay in recognition of this event as an incident involving a WMD affect your procedures?

The emergency operations plan (EOP) of each jurisdiction and agency should contain an outline of notification procedures. The EOP review completed by the facilitator during the development portion of this activity should provide adequate detail to support facilitated discussion. The following provides general guidance.

In many jurisdictions, the 911 dispatcher serves as the hub of the notification system and notifies certain agencies or certain individuals, or both. In the case of anthrax and other biological agents with delayed effects, the activation and notification process would be more deliberate than normal. In many cases the EOC will become progressively staffed as the incident matures. By the time the event is recognized as an incident involving a WMD, most of the staff may be on site.

In most jurisdictions, the police and fire departments have excellent internal

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

notification systems; however, other participating agencies may not. Check this during the EOP review. During the discussion explore if or how the police and fire departments could assist other agencies.

Walk participants through each step of the notification and activation process for an incident with immediate effects, for example, an incident involving a large bomb or a chemical WMD. Let them estimate their time of arrival and where they will be reporting. Contrast that approach with the delays associated with knowing that a biological incident has occurred.

Follow-up Questions:

Does your jurisdiction have a policy that prevents full activation of the emergency management system when it is not needed? How does the slow-to-develop nature of this incident affect your procedures?

The screening process should be defined in local EOPs and often relies on the local office of emergency management or the EOC (if it is staffed 24 hours a day) to serve as the decision maker.

The slow-to-develop nature of this incident will affect the EOC activation procedures dramatically. Use the EOP review to gain additional insight into how this issue will likely be addressed.

Who handles notification of state and federal authorities? Will the National Response Center be notified in this scenario?

The responsibility for state and federal notifications should be clearly defined in the local plan. For an incident of this magnitude, once the terrorism link is established, the National Response Center should be notified.

Without indicators of widespread immediate effects, will an incident command system (or other management) structure be established? How will the incident commander be determined?

Explore with the participants when or what staffing level constitutes a management structure that is operational.

2. What information, equipment, and actions are required by your jurisdiction to conduct the initial assessment of the incident? How do you anticipate information to be distributed among responders?

Allow the group to brainstorm.

Items discussed should include the following:

  • a method to determine the numbers and locations of all patients with signs and symptoms similar to those of the dead airport workers,

  • a method to determine the source and identity of the infectious agent and the extent and area of contamination, and

  • a method to determine the decontamination requirements.

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

The plan review should provide details on the method for sharing information with responders.

3. What immediate decisions related to protective actions that should be taken should the jurisdiction make? How will those decisions be implemented?

Decision making related to the protective actions that should be taken is a critical issue, and the participants should be allowed sufficient time to discuss the ramifications of their decisions. The issue of evacuation versus sheltering versus quarantine should be explored. The EOP should provide a framework for making such decisions. In the case of biological agents with delayed effects, the “cat is most likely already out of the bag.” Sheltering is not a viable option at this point. The immediate area and adjacent buildings should be evacuated because of the risks associated with inhaling particles resuspended in the air. Those assisting with any evacuation must use at least simple respiratory protection, and an area at the collection center should be designated for medical screening of evacuees. There will most likely be tremendous political pressure, especially from adjacent jurisdictions, to quarantine anyone who could have been exposed to a suspected biological agent. This should be considered a viable option because the specific agent has not been identified at this point of the scenario. Revisit this issue during the next scene after anthrax has been identified, because anthrax is not normally considered contagious.

Allow participants to discuss the issues of decontamination and triage strategies.

Follow-up Questions:

Should the jurisdiction be concerned about the possibility of additional attacks?

This is always a possibility, and the group should discuss what changes they will have to make to manage additional incidents of either a terrorism event involving a WMD or more common emergencies (e.g., fires and auto accidents).

What medical facilities are victims or patients being sent to? What types of information should the emergency medical services units relay to the hospitals in the area to prepare them to receive patients potentially contaminated with an unknown hazardous material? Should any areas be quarantined?

These questions focus on the initial medical response. Allow the participants to discuss this topic, if they bring it up. If an examination of this topic is not initiated by the participants, it will be fully examined during the discussion associated with Scene II.

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

4. How will the incident site be secured to ensure that the crime scene is protected after such a significant time delay? What access and egress control procedures should be implemented?

The EOP should provide details on contamination control procedures and crime scene protection as part of its WMD annex, if it exists.

Allow the participants in the group to discuss their security procedures and how these relate to their overall response strategy.

Access and egress control procedures should be included in the hazardous materials (hazmat) portion of the local plan. Determine the group’s understanding of the importance of this issue.

5. Is the current number of trained, qualified personnel within your jurisdiction sufficient to respond to this incident? If not, where will you seek support to bridge these deficiencies?

A review of the EOP should provide an indication of the number of trained and qualified personnel.

Mutual support agreements with other local governments and state agencies should be discussed at this point.

The state EOP should be activated. The group should discuss how activation of the state EOP will affect operations.

The National Strike Force, the U.S. Department of Defense, and the Public Health Service are among the federal agencies with expertise in this area.

6. Will the city or county EOC be adequate for coordinating the response to this incident? Will a separate command center that is physically close to the incident site be required? What resources are available for outfitting this command center?

This information should be extracted from the EOP. It is assumed that an incident command system will be used.

Follow-up Questions:

How long will it take to have an EOC activated and fully operational? What are the capabilities of the center? Are these capabilities adequate to respond to an incident of the magnitude presented here?

In this scenario, the command post should be at the local EOC, so the answer will depend on how long it will take to activate the EOC and staff it appropriately and on whether the local EOC is in the affected area. If so, the use of an alternate site should be discussed.

The capabilities of the local EOC and the alternate EOC should be apparent from the plan review.

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

Instructor’s Background Information on the Incident, Scene II

It is now 8:00 a.m. (0800 hours) on [day, date of the 6th day of the scenario], approximately 120 hours after the initial release of anthrax spores into the air ducts at [name of airport] and approximately 64 hours after the first airport workers complained of illness. At this point, the FBI is called to respond to the suspected terrorist attack. President [name of U.S. president] has not issued a disaster declaration through the Stafford Act; hence, the Federal Response Plan is not activated. At 5:00 p.m. (1700 hours), the president issues a disaster declaration for the state. The FBI is already on scene, but FEMA is not. The FBI initiates the structure for crisis management and takes the lead in the criminal investigation. When FEMA arrives, the structure changes to reflect the need for FEMA to lead the federal consequence management effort under the Terrorism Annex of the Federal Response Plan. Because the Terrorism Annex is a new addition to the Federal Response Plan, it is likely that participants in this exercise will not be familiar with the differences in these structures. Some additional guidance in these areas may be necessary.

The presence of anthrax is first suspected 122 hours after spore release [10:00 a.m. on day 6], although it is not confirmed through laboratory testing until 136 hours after spore release. The persistence of anthrax spores creates major problems, as the spores can be spread to other locations via people or equipment contaminated at the original site of spore release.

Thousands of travelers are stranded because of the shutdown of the airport; international and domestic flights are rerouted to other airports, increasing air traffic and causing delays in those areas. Airports to which flights are diverted are: [provide a list of regional and local airports to which traffic for the area could be diverted.] Many passengers who were contaminated at the airport continued their travels to other parts of the country and the world. The instructor should insure that the participants consider the difficulties associated with decontaminating all these individuals, and consider the consequences of failing to do so.

The huge number of casualties in this scenario quickly exhausts the limited local supply of medicines such as broad-spectrum antibiotics. Triage may be conducted as part of an actual response effort; the emphasis is placed on saving as many lives as possible, which means that the worst-off individuals who are likely to die are lower in treatment priority than individuals who can clearly be saved. It is noteworthy, however, that experience with victims of the anthrax spore-laden letters of October 2001 suggests that inhalation anthrax is not uniformly fatal even when treatment begins after patients are symptomatic.

The vast majority of B. anthracis strains are sensitive in vitro to peni-

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

cillin. Penicillin-resistant strains exist naturally; and it is not difficult to induce resistance to penicillin, tetracycline, erythromycin, and many other antibiotics through laboratory manipulation of organisms. All naturally occurring strains tested to date have been sensitive to erythromycin, chloramphenicol, gentamicin, and ciprofloxacin. In the absence of information concerning antibiotic sensitivity, at the earliest signs of disease treatment should be instituted with oral ciprofloxacin or intravenous doxycycline every 12 hours. Supportive therapy for shock, fluid volume deficit, and maintenance of adequacy of the airway may all be needed. In cases in which a biological weapons attack is suspected, prophylaxis with ciprofloxacin or doxycycline is recommended for any individuals likely to have been exposed.

Means of vehicular access to the airport area are crowded, and great confusion exists. Approximately [provide the approximately number of people that travel through the airport each day] travel through the airport each day, so a total of [number per day times seven] people traveled through the airport in the week before the shutdown was ordered. Once a biological weapon agent is suspected, the response to the scene changes dramatically. Decontamination needs to be performed for persons (and their personal belongings, e.g., clothing and baggage) who had been or who are inside the airport and its immediate vicinity, including passengers, airline and airport workers, and response personnel already on the scene. Self-contained breathing apparatuses (SCBAs) need to be procured and used, although a filtering mask may be sufficient (most fire departments carry SCBAs at all times, but it would be unlikely that they would have enough equipment to supply SCBAs to all those responding to this incident). Protective clothing needs to be procured and worn by both law enforcement and medical investigators. “Hot,” “warm,” and safe zones need to be defined.

Individuals thought to have been exposed should begin a 60-day course of antibiotic treatment; if clinical signs of anthrax occur, patients should be treated as described above, but they will need additional supportive care, almost certainly as inpatients. If the anthrax vaccine is not available, antibiotic treatment should be continued for an additional 40 days.

If the anthrax vaccine is available, patients should be offered the option of vaccination at this point as protection against the possibility of very late germinating spores. It is believed that individuals must be exposed to a series of six vaccinations over a period of 18 months before the vaccine can be fully effective, but limited data from studies with humans suggest that completion of the first three doses of the recommended six-dose primary series (at 0, 2, and 4 weeks) provides some protection against

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

both the cutaneous and the inhalation forms of anthrax. Contraindications for use of the vaccine are sensitivity to vaccine components (formalin, alum, benzethonium chloride) and a history of clinical anthrax. Reactogenicity is mild to moderate and lasts for up to 72 hours (tenderness, erythema, edema, or pruritus). A smaller proportion of individuals (<1 percent) experience more severe local reactions (e.g., anaphylaxis, which precludes additional vaccination). The vaccine should be stored at refrigerator temperature (it should not be frozen).

Hospitals in the area that serve patients contaminated with anthrax are [list the hospitals and medical centers with the capability of treating mass casualties]. Hospitals outside the immediate area that serve as back up are [list nearby regional medical facilities that could be used, especially any facilities that have mutual-support agreements with local facilities].

The primary focus of this session should be the recognition that federal assistance, whether it is requested or not, is on the way. The scenario is designed to overwhelm the local and state response capabilities. The challenge is integrating the local response with federal and state interests. The criminal investigation, coordinated by the FBI, has the potential to conflict with the humanitarian aspects of the response. This conflict was demonstrated in the TWA Flight 800 incident: families wanted the priority placed on body recovery, thus slowing down the investigation.

The instructor should describe the transition from use of the incident command system initially established at the scene to use of a the larger unified command that encompasses all agencies. If the group’s assumptions about how this works appear inaccurate, the instructor must provide the necessary corrections.

A host of federal agencies are potentially involved. Besides the CDC and the FBI, they include elements of the Environmental Protection Agency, the U.S. Department of Health and Human Services, the U.S. Department of Transportation , and the U.S. Department of Defense. Optimal use of the resources of these agencies is a challenge in a real incident. A very important nonfederal agency is the American Red Cross, which offers invaluable assistance in dealing with family notification and reunification issues, as well as assisting stranded travelers. The American Red Cross may have difficulties with volunteers (and contracted responders) because they refuse to service the area or victims for fear of becoming infected.

The resources most likely required from the state National Guard include transportation, communications, and security, as well as expertise and resources related to biological warfare.

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

Scene II: Chaos in the City

It is still [day of week, date of the 6th day of the incident in the scenario] in [city, state, of the incident in the scenario]. The temperature is currently [midday temperature in degrees Fahrenheit forecast for the scenario] with an expected high temperature for the day of [high temperature in degrees Fahrenheit forecast for the scenario].

It is [date of 6th day], at 8 a.m. (0800 hours). Hospitals and local clinics note that people complaining of flulike symptoms and others in more advanced stages of infection continue arriving at epidemic levels. Most have either passed through the airport or come into close contact with someone who has. An autopsy of one of the first victims reveals that respiratory arrest precipitated death. Greatly oversized mediastinal lymph nodes are consistent with the hypothesis of anthrax. The six initial victims taken to [name of largest hospital in the area] all died, and autopsies of these victims also report enlarged mediastinal lymph nodes and respiratory arrest as the cause of death. Because of the suspected use of anthrax spores, cultures for the biological agent are requested. Results from the cultures are not available for at least another 12 hours.

Suspicion of the presence of a biohazard causes local authorities to keep the airport closed. Local response agencies are overwhelmed with the numbers of potentially exposed persons demanding treatment, potentially infected rescue personnel, and an increase in media interest in the incident. The governor declares a state of emergency, and immediately requests a presidential disaster declaration.

At 4:45 p.m. (1645 hours) on the same day, the FBI arrives and takes charge of the criminal investigation. A CDC investigative team arrives and begins laboratory processing to confirm the state laboratory diagnosis of anthrax. The CDC has flown a “push package” of pharmaceuticals and medical supplies from the National Pharmaceutical Stockpile into a neighboring city, but distribution is slow and hospitals are running out of antibiotics.

Airport personnel estimate that between the time of the first reported incidents and the subsequent closure of the airport facilities [develop estimates based upon actual average passenger rates at the airport], [estimated number] passengers continued through the airport to other destinations and [estimated number] remained in the metropolitan area.

Reports regarding significant numbers of similar types of deaths from [names of four largest metropolitan destinations from the airport site of the incident] metropolitan areas are broadcast over a major national cable news network. It is anticipated that [appropriate percent of total number] of passengers and [appropriate percent] of airport workers may be infected with the agent.

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

The number of potentially infected residents of the metropolitan area is not known. However, the CDC estimates that thousands of deaths may be anticipated within the next 48 hours if anthrax is the causative agent. Airport officials conducting an investigation determine that most of the more seriously ill airport workers and those who were initially sick work in the check-in and baggage claim areas. The FBI sends an investigative team to each area in an attempt to locate the origin of the incident.

On the same day, at 5 p.m. (1700 hours), the U.S. president issues a disaster declaration through the Stafford Act, activating the Federal Response Plan. The FBI Joint Operations Center, as described in the Federal Response Plan Terrorism Annex, is established and the Domestic Emergency Support Team is dispatched to [location of the incident]. One of the National Emergency Response Teams is flown in from FEMA headquarters. All lead agencies for emergency support functions are notified to assemble their teams for deployment to the Disaster Field Office once it has been designated. The Disaster Field Office, which will have additional federal resources, should be fully staffed and equipped in approximately 24 hours.

Traffic congestion from the self-evacuation of some neighborhoods interferes with response operations. The American Red Cross reports a shortage of shelter volunteers. Most fear coming into contact with contaminated residents and becoming infected.

Hospitals, clinics, and doctors’ offices in the area are overwhelmed with people who fear they may have been exposed to anthrax and are demanding prophylactic antibiotics.

On [day, date of the 7th day of the scenario], at 2 a.m. (0200 hours), laboratory analyses conducted by the CDC confirm that B. anthracis spores are the infectious agent causing the epidemic. The CDC notifies state and local response agencies. They also report that the quantities suggest intentional dispersion by a terrorist group. Information on the symptoms, decontamination procedures, and treatment for anthrax is disseminated to hospitals and to local, state, and federal response agencies as they arrive on the scene. Because of the vast number of infected people, the CDC and the state health department estimate that contamination of the airport began 5 to 7 days earlier.

Samples collected and sent to laboratories for testing indicate that a portion of the city near the airport is contaminated to some extent.

In a statement to the press, President [name of the U.S. president] condemns the vile act of terrorism and vows to apply the full force of the government to punish the culprits.

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

Questions, Scene II

1. Who is in charge of the incident site? How will your agency’s actions be coordinated with the actions of other agencies? What conflicts could arise from the need to simultaneously conduct extensive criminal investigatory and response functions? What conflicts may be anticipated between the overlapping federal, state, and local jurisdictions?

Explore the federal definitions of crisis management and consequence management. At the federal level, the FBI has authority over the incident site and is responsible for crisis management. FEMA has federal authority for consequence management, but it must conform to the directions of the FBI to protect as much of the crime scene as possible while providing the needed rescue and relief to protect the population. The Public Health Service and the CDC both have significant roles in consequence management when they must respond to biological agents. It is anticipated that most jurisdictions will follow this delineation of responsibilities.

Determine who is in charge of the local response for both consequence and crisis management and explore the role of the health department.

Determine the command or management structure to be used by the jurisdiction. The Incident Command System has been adapted by many jurisdictions as their command structure during response operations. Explore the specifics of the local system during this discussion. A review of the EOP should have provided details on the structure of the command structure.

Conflicts will likely be related to the jurisdiction’s attempt to balance protecting evidence and protecting people. Overlapping conflicts can occur as state and federal responders arrive on scene and the transition to a unified, joint, or coordinated command or management structure begins. During a health emergency the additional authority granted to the health department is also a source of potential conflict.

2. What community health planning has been completed? Have privately owned hospitals, home-care agencies, long-term-care facilities, and clinics been incorporated into the EOP and included in the planning process? Has your community conducted joint exercises for this type or any type of mass-casualty situation?

The EOP review should indicate the preparedness of the community health program to address mass-casualty situations and the involvement of all local health care assets in the planning process.

Most jurisdictions should have been involved in joint mass-casualty exercises because these are an accreditation requirement for most health care organizations, especially hospitals.

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×
Follow-up Questions:

What community medical operations might be necessary?

This issue should be addressed in the community health plan as it exists. The priorities at the scene should be gross triage and screening at some type of collection or screening point. Transportation of potentially affected members of the population is another operational issue that should be addressed.

Will triage stations be established? Where will these be established?

The discussion of triage should focus on managing the flow of casualties through the community health system. The community health plan should address this issue.

Triage protocols at both collection and delivery points should also be part of the plan. Basic requirements dictate that triage be performed at both locations. This may be a good point to address the differences between standard emergency room triage and mass-casualty triage in most incidents involving a WMD. Contrast the immediate lifesaving needs associated with threats such as chemical agents and the more deliberate, supportive approach associated with biological agents.

What specific assistance do you need from the state and federal governments? How will these resources be integrated into the response operations?

State and federal plans provide for mobilization of these types of resources in disaster situations. It is important for the group to realize that there may be a significant time delay before those resources are available.

What type of epidemiological surveillance program does your community have in place? How well defined are the linkages between the community health program and plan and your consequence management infrastructure?

Epidemiological surveillance is important in determining the number of individuals who were exposed to the biological agent. Community health planning should account for locating within the incident area personnel who may be asymptomatic at this point, especially in light of the potential delayed and long-term health effects.

The community should consider establishing a database to track the health of those members of the community, including responders, who may have been exposed to anthrax.

The EOP should define the linkage between the community health program and the emergency operations management structure, and a representative of the community health agency or emergency medical services should be on the management team.

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

3. What immediate public relations and media concerns must be anticipated? How will these concerns be addressed? Who will serve as your jurisdiction’s spokesperson in this incident?

The Joint Information Center should be established after the arrival of state and federal assets and should serve as the source of pubic information after that point. The plan should identify who will serve as the local spokesperson before the establishment of the Joint Information Center.

Most EOPs assign the management of public affairs issues to the management team located in the EOC. Determine participants’ familiarity with public affairs procedures. Anticipating that public panic and extreme fear are likely to exist, the group should discuss how to diffuse the issue without denigrating the seriousness of the situation. Determine if the participants understand the importance of a multimedia approach and the development of themes.

Follow-up Question:

Does the communications system meet the multilingual needs of the area?

The EOP review should identify the multilingual needs of the community and procedures for meeting those needs.

4. What are the internal and external communications requirements for this response? Who is responsible for ensuring that the necessary systems are available? What problems may be anticipated?

The EOP should address internal and external communications requirements and assign responsibility for maintaining a viable system. Communications support equipment is normally located in or adjacent to the EOC.

Internal communications issues focus on the ability of jurisdictions to communicate with responders from different agencies (e.g., fire departments talking to police). Determine what system is in place to facilitate such coordination or if coordination must be accomplished face to face, through dispatchers, or through the EOC.

External communications issues should focus on the procedures for providing essential information to state and federal responders and managers who are en route to the incident site.

Solutions that rely on public hard telephone lines or cellular telephone systems should be discouraged in light of the numerous demands that will be made on those systems, unless the plan review revealed that a priority override system for emergency communications is in place with local telephone service providers.

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

Instructor’s Background Information on the Incident, Scene III

It is now 8:00 a.m. on [date of the 7th day of the scenario], 6 full days after the release of anthrax spores at the airport. At this point, the FBI has effectively established control of the situation for crisis management purposes. The casualty figures could be horrendous. The potential for further spread of the spores exists, but levels of contamination beyond the airport and the surrounding neighborhoods may be so low that no further deaths may be reported due to the additional spread. The CDC is actively involved in supporting the community’s consequence management effort, and adequate amounts of antibiotics are rushed to local treatment centers.

The response required all of the city’s emergency response forces and most of those available from the county and other nearby cities. The stress and trauma of dealing with death on such a large scale affect many responders at the scene.

Crew relief schedules should be discussed in this session. Decontamination is expected to last many weeks, and no decision is made yet about airport operations.

The extended use of police and security forces can lead to problems in other areas of the city. In addition, the overload on the city’s telephone system makes it nearly impossible to call anywhere in the area.

Scene III: The Immediate Threat Wanes

It is 9 p.m. (2100 hours) on [day of week and date of 6th day of scenario] in [city, state, of the incident in the scenario].

Additional medical supplies arrive on the scene and at local hospitals, including large quantities of ciprofloxacin and doxycycline.

Standard antibiotics are ineffectual in fighting anthrax infection among victims. Further studies conducted by the CDC indicate that the strain of anthrax used in the release may have been biologically manipulated to resist treatment and initiate symptoms much faster than normal. Hospitals seek additional information from the CDC as to what other courses of treatment may be used to combat anthrax infection.

The Disaster Field Office is established at [location of Disaster Field Office] and is fully staffed and equipped by the morning of [7th day of the scenario].

There are concerns about disposal of the victims’ bodies. The number of victims and fear of spreading anthrax spores create problems with storage of the remains. The number of bodies collected overwhelms the city morgue and surrounding morgues. The total death count is more than 1,000. Hundreds of more deaths are anticipated. Families of the victims call local hospitals to arrange for retrieval of their loved ones’ bodies for burial.

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

The CDC continues to collect samples from the areas downwind of the airport.

On the morning of [date of the 8th day of the scenario], at approximately 9 a.m. (0900 hours), airlines contact the CDC and the state health department with questions about testing for anthrax contamination on aircraft, equipment, and other potentially contaminated areas. They want to know what decontamination procedures will ensure the safety of their aircraft. Aircraft operators also ask if and when the airport will be safe to resume normal business.

The CDC and the state health department continue to generate detailed information on appropriate methods for the cleanup of contamination with anthrax spores. Information on long-term cleanup of the airport and affected areas indicates that thorough cleaning of the airport and surrounding areas must be completed before the areas can be reopened for normal business. President [name of the U.S. president] has already made it clear to the public that the airport will not reopen until laboratory testing confirms that it is free of contamination with anthrax spores.

Later that morning, FBI investigative teams locate the canisters used to spread the anthrax in the air ducts of the baggage claim and ticketing areas. There are no leads to the perpetrator(s) of the attack at this time. However, the FBI confirms that this incident is unquestionably a terrorism incident.

Media interest in the incident captures worldwide attention as the total victim count is confirmed. The incident sends shock waves through the country. People nationwide cancel flights and opt for alternate modes of transportation.

Representatives of the media transmit live interviews from the city reporting that residents are reluctant to return to their homes, despite assurances that it is safe to reenter designated areas.

Questions, Scene III

1. How will you conduct extended response operations? Are local personnel and equipment resources adequate for the extended operations required?

The EOP should account for round-the-clock operations. Many jurisdictions plan to send a portion of the EOC staff home after the initial incident assessment reveals the need for extended operations. Determine who will be responsible for each function on multiple shifts.

Each agency will likely be overwhelmed. The real question is how much state, federal, or National Guard support is needed.

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

2. What are your procedures for integrating state and federal resources into your management organization?

The EOP should outline the procedures for integration of state and federal resources.

State and federal assistance is supplementary to the local response; and as the Disaster Field Office is established, the Federal Coordinating Officer and State Coordinating Officer will coordinate the activities of the state and local governments, the American Red Cross, the Salvation Army, and other relief and disaster assistance organizations.

Follow-up Questions:

How will your agency coordinate its action with other agencies (federal, state, and local) and public interest groups?

The Federal Coordinating Officer is the primary federal coordinating authority for consequence management; the FBI handles crisis management.

With the arrival of state and federal assistance and the formation of a Joint Information Center, how will media inquiries be handled? Who in your jurisdiction is responsible for authoring media releases?

Media releases must be coordinated with the FBI, FEMA, and state and local authorities once the Federal Coordinating Officer has been established.

The EOP should provide a detailed communications and public relations plan.

3. What continuing assessments should be enacted when the cleanup phase is complete? Who will make these determinations?

Long-range health issues are of great concern.

The EOP should provide an overview of how continuing assessments and long-term monitoring are accomplished. Allow the participants in the group to discuss their areas of concern and to propose priorities.

4. What are the environmental concerns related to this incident?

Materials used during the response to support decontamination operations will continue to present hazards until they are neutralized.

Follow-up Questions:

What steps will be taken by your agency to ensure adequate sanitation measures throughout the affected area?

The local hazmat plan should identify sanitation procedures related to biological operations.

What local requirements exist for reentry to an evacuated area due to a biological agent incident?

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

The hazmat annex to the EOP should outline procedures for reentry into an evacuated area.

After the use of an especially persistent biological agent such as B. anthracis, the local emergency management team should consider the need for “safe certification,” that is, having a third-party laboratory verify that the area is free from contamination.

5. Within your jurisdiction, what psychological traumas may be anticipated? How will your agency deal with these traumas?

Many agencies have teams already designated to assist in such cases. In most instances, the teams will not have the capacity to handle the expected number of cases in an incident of this magnitude.

Discuss the availability of crisis counseling. Also, refer participants to Section 416 of the Stafford Act.

Follow-up Questions:

How will your agency participate in notification of the deaths of civilians and your colleagues? Are personnel in your agency adequately trained in the process of death notification?

Death notification is always a difficult issue. The EOP should provide guidance to managers. However, at a minimum someone in the supervisory chain should be involved with the actual notification.

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

CHEMICAL SCENARIO (SARIN)

Potential Participants

Fire department

Police department or sheriff’s office

Office of Emergency Services

Public works department

Public health department

Public information officer

General counsel’s office

Medical examiner or coroner’s office

Emergency department physician

Transportation authority (port authority, airport authority, etc.)

Coordinator of volunteer organizations

Emergency medical service

Hazardous materials team

State emergency management office

Area military and local federal facilities

National Guard

U.S. Department of Energy

Federal Bureau of Investigation

Public Health Service

Centers for Disease Control and Prevention

Environmental Protection Agency

U.S. Coast Guard

Representatives of neighboring jurisdictions

The list is not intended to be either prescriptive or inclusive.

Instructor’s Background Information on the Incident

This scenario involving terrorism with a chemical weapon of mass destruction (WMD) portrays an incident that local response groups and agencies can use to evaluate their coordination and response capabilities. They may also identify shortfalls in personnel or other resources that can be supplemented by state or federal sources. The scenario is intended to portray only the hypothetical technical features of a chemical terrorism incident and does not represent an actual event.

This scenario takes place in [city, state]. [A brief description of the location of the chemical incident, a shopping mall located within the jurisdiction participating in this activity. If the mall is named, use the proper name and highlight some of the major tenants. The mall selected, if more than one is available,

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

should be the one closest to the center of town or major traffic arteries. The description should also include information on the number of shoppers found at the mall on an average day.]

In this scenario, a terrorist group has obtained 8 gallons of the nerve agent sarin (GB is the international military symbol)) and puts this liquid nerve agent into four 2-gallon pressurized metal containers with aerosol release valves. The mall ventilation system carries the agent throughout the mall and to surrounding parking lots, where it will not survive for very long. The release has the potential to affect everyone within the mall and a large number of people in the surrounding area.

The effects of a sarin release of this form (aerosol) are instantaneous. These include blurred vision, breathing difficulty, gastrointestinal distress, skeletal muscle paralysis, seizures, loss of consciousness, and death.

The four sarin containers are placed inside open-top trash cans inside the mall. These are simultaneously released during the height of the lunch hour, when the mall experiences its peak occupancy for the day. The terrorists placed the canisters in the outer-perimeter hallways of the first floor of the mall, effectively blocking ground-level entrances. The release disperses the sarin from each canister into the atmosphere, directly contaminating many people.

In this scenario, it should be apparent that a nerve agent is involved. However, responders cannot identify the type of agent released. Thus, for the purposes of this scenario, consider decontamination aspects. The medics responding to the scene have Occupational Safety and Health Administration training and should recognize some of the symptoms. If not, the sequence of events and the massive number of casualties should indicate that a gas release has occurred.

Vehicular access to the incident site (the mall) is complicated by the fact that the release spawns general panic, leading to spontaneous evacuation of the surrounding area. Responders should know their limitations. Moreover, unaware of the presence of gas upon arrival, many of the first responders are exposed to the sarin.

At some point, it should be obvious that the casualties require decontamination before they can be treated by unprotected medical personnel or before casualties can be allowed to depart the area. Furthermore, casual exposure to the nerve agent increases the number of casualties. In the case of sarin (a nonpersistent agent) this is NOT a major issue; however, it must be seriously considered. Persons exposed to very small amounts of the nerve agent show limited symptoms and can be successfully treated if the symptoms are noted in time and the proper antidotes (especially atropine) are available. One should expect, however, countless individuals exhibiting symptoms based on stress and hysteria rather than actual exposure.

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

It should be easy to determine that this is a terrorism incident. As such, the Federal Bureau of Investigation (FBI) must be notified. The instructor should explore how this notification will take place. This also raises many command and control issues that will be explored further in Session II.

The evaluator should customize Scene I on the following pages and provide it to each of the participants.

Scene I: The WMD Event Occurs

[City, state, of the incident in the scenario], [day of week, date of the incident in the scenario]. The weather forecast predicts [insert the weather forecast for the scenario within the normal range for the date of the exercise; include the daily temperature range, the amount of cloud cover, and the wind speed and direction; if possible, set up the scenario for a calm, cool, overcast day]. At midday it is [temperature, in degrees Fahrenheit, within the forecasted range].

At 12:15 p.m. (1215 hours), the [name of the mall involved in the incident in the scenario] is filled with lunch-hour shoppers, and the surrounding parking areas are congested with higher than normal levels of traffic.

At 12:30 p.m. (1230 hours), a 911 dispatcher receives a call from the [name of mall] security manager ([name of security manager]). He or she reports that hundreds of customers inside the mall are gasping for air and convulsing. Hundreds more are collapsing. He or she is evacuating the mall and needs help. First responders are immediately dispatched to the scene. Within minutes, other callers report seeing people collapsed outside the [name of the mall].

After dispatching emergency units to the site, the 911 center notifies the municipal switchboard. Reports of casualties at the mall follow. Fire and police squads and medical emergency units arrive on site and initiate emergency response operations. The [title and name of the chief executive of the jurisdiction, e.g., Mayor John Smith of Central City] is notified that a crisis of potentially major proportions is unfolding. Major highways and access roads are congested with heavier than normal traffic and scattered traffic collisions in the immediate area caused by individuals fleeing the mall after seeing people collapse, making the response more difficult.

People inside the mall and in the parking lots near the building exits and vents appear to have been exposed to an unidentified substance and are convulsing and asphyxiating. Some are shaking uncontrollably and sweating profusely. Many appear dead, and others who are severely incapacitated require immediate medical assistance. Victims are transported to area hospitals, but some first responders at the response site exhibit similar symptoms and need immediate medical attention. Residential areas in the surrounding areas appear to be unaffected.

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

At 1:45 p.m. (1345 hours) the state Emergency Operations Center (EOC) in [location of state EOC] is activated. At 2:15 p.m. (1415 hours), a representative from the news division of [name of local television station] contacts city officials to report that an unidentified caller claims to have released a nerve agent at [name of the mall] that afternoon as the first part of a coordinated terrorist attack against [incident city]. The television station goes live with the story moments later.

By 3:30 p.m. (1530 hours), the emergency departments at [names of all medical centers, hospitals, or major trauma facilities] report that some of their personnel exhibit the same symptoms as patients from the mall. [The name of the second largest medical center or hospital in the area] reports that its emergency department is operating at full capacity, that it has activated its mass-casualty disaster plan, and that it is unable to care for additional victims. Designated trauma centers request technical information regarding the agent used in the terrorist attack. Medical collection points are established around [at least two named locations located a minimum of two blocks upwind from the mall]. [The name of the largest medical center or hospital in the area] reports that tissue and blood samples from several of the victims were packaged as extreme biohazards. The samples were sent to the [appropriate advanced forensics, academic, or hazardous materials (hazmat) laboratory in the area or region; it should be reachable within a couple of hours, if possible] by special courier.

National television broadcasts linking with local affiliates show live pictures of the incapacitated and the dead being removed from the mall. Reporters request information regarding the city’s response to and preparedness for this type of incident. A major national cable news network requests an interview with a representative from the city.

Residents within 2 miles of the affected mall spontaneously evacuate their homes, frightened by the images on television. Traffic bottlenecks form on all major city transportation arteries, including [name of one or two major transportation arteries normally used during emergency responses], further complicating response activities. The combination of spontaneous evacuees and above-normal levels of traffic result in virtual gridlock throughout the area.

Facilitated Discussion

Purpose

This guided group discussion is designed to help participants understand the types of issues that they will encounter and the conflicts across agencies and jurisdictions that can occur in coordinating, communicating,

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

and responding to such an incident. It also gives participants an opportunity to assess their jurisdiction’s ability to respond to such an incident.

Presentation

Provide participants with a copy of the questions that does not include the answers to questions, additional questions, or the final note to the facilitator.

Guide a group discussion by asking the numbered questions on the following pages. These questions are not all inclusive; use them to develop additional questions, as necessary. Some additional questions are included should there be a need to stimulate further discussion.

Don’t forget that good facilitators speak much less than the participants. This is an assessment activity, not a formal instructional class.

Be sure to touch on the following areas: direction and control, notification and activation, communications, warning and emergency public information, hazard assessment, and management of field response.

Questions, Scene I

1. How will you learn of this incident involving a WMD? What internal and external notifications should you make? Are you satisfied that the current notification process is timely and adequate?

Each jurisdiction and agency should have notification procedures outlined in their emergency operations plans (EOPs). The EOP review completed by the facilitator during the development portion of this activity should provide adequate detail to support facilitated discussion. The following provides general guidance:

–In many jurisdictions, the 911 dispatcher serves as the hub of the notification system and notifies agencies and/or individuals.

–In most jurisdictions, the police and fire departments have excellent internal notification systems; however, other participating agencies may not. Check this during the EOP review. During the discussion explore if or how the police and fire departments could assist other agencies.

–Walk participants through each step of the notification and activation process. Let them estimate their time of arrival and where they will be reporting. Do they anticipate any traffic, transportation, or communication delays that could significantly affect their response? Is there a system in place to facilitate notification when individuals are out of the office, for example, at lunch or at a meeting? How would the lower levels of staffing normally associated with the lunch hour affect the notification process?

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×
Follow-up Questions:

Does your jurisdiction have a policy that prevents full activation of the emergency management system when it is not needed?

The screening process should be defined in local EOPs and often relies on the local office of emergency management or the EOC (if it is staffed 24 hours a day) to serve as the decision maker.

Who handles notification of state and federal authorities?

The responsibility for notification of the state and federal authorities should be clearly defined in the local plan. For an incident of this magnitude, the National Response Center should be notified.

If this incident involving a WMD actually occurred, how long would it take responders to arrive on the scene? How long would it be before an incident command (or other management) structure is established?

Each agency present should provide estimates, and the participants should try to reach a consensus on the overall response time.

Explore with the participants when or what staffing level constitutes a management structure that is operational.

2. How will identification of the presence of hazardous materials occur? How will confirmation of the type of chemical hazard occur?

The EOP review should provide details on how the hazardous materials team (HMT) identifies “unknown agents,” because it is unlikely that the local team could readily identify sarin. Supporting laboratories in the area should have been preidentified and agreed to support jurisdictional emergency response operations. Additional information can be obtained by the following:

–M-1 Chemical Agent Detector Paper and the M256 Chemical Agent Detector Kit can both identify the presence of nerve agents. Both are commonly used by military units; however, most fire departments and hazmat units are not equipped with this technology and must be cautious when using it. Query the group to see if they know how to obtain the materials. The M256 kit is more effective for identifying sarin because it is designed to primarily detect vapor hazards.

–The HMT should carry mine safety association detector tubes or similar systems that will capture a sample of the air; however, these will NOT make a positive identification of the presence of a nerve agent.

Follow-up Questions:

Will responders and/or hazmat units recognize the symptoms associated with nerve agents? Will responders test the air before responding?

The answers to these questions should be indicated through review of the EOP and the discussion associated with Question 3 below. Here, issues such as

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

response, protection of the population, and rescue versus self-preservation and maintenance of a response capability should be addressed (i.e., responders should not be used as detectors or allowed to become victims).

3. What information, equipment, and actions are required by your jurisdiction to conduct the initial assessment of the incident? How do you anticipate that information will be distributed among responders?

Include the following items in your discussion:

  • a method to determine the identity of the agent,

  • a method to determine the extent or area of contamination, and

  • a method to determine the decontamination requirements.

4. What immediate decisions related to protective actions that should be taken should the jurisdiction make? How will they be implemented?

Decision making related to the protective actions that should be taken is a critical issue, and the participants should be allowed sufficient time to discuss the ramifications of their decisions. The whole issue of evacuation versus sheltering should be explored. The EOP should provide a framework for making such decisions. In the case of sarin because it poses a significant vapor hazard, sheltering is not an appropriate response. The immediate area, adjacent buildings, and the hazardous area downwind should be evacuated.

Allow participants to discuss the issues of decontamination and triage strategies.

Follow-up Questions:

Should the surrounding area be evacuated in this case, or will sheltering be an appropriate response?

Should the jurisdiction be concerned about the possibility of additional attacks?

This is always a possibility, and the participants in the group should discuss what changes they will have to make to manage additional incidents of either a terrorism event involving a WMD or more common emergencies (e.g., fires and auto collisions).

What medical facilities are victims and patients being sent to?

What types of information should the emergency medical service units relay to the hospitals in the area to prepare them to receive potentially contaminated patients? Should any areas be quarantined?

These questions focus on the initial medical response. Allow the participants to discuss this topic, if they bring it up. If discussion of this topic is not initiated

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

by the participants, it will be fully examined during the discussion associated with Scene II.

5. How will the incident site be secured to ensure that the crime scene is protected and no contaminated personnel or equipment leave the area? What access and egress control procedures should be implemented?

The EOP should provide details on contamination control procedures and crime scene protection as part of its WMD annex, if it exists. The EOP review should also provide an indication of how the jurisdiction will manage these issues.

Allow the participants in the group to discuss their security procedures and how these relate to their overall response strategy. Access and egress control procedures should be included in the hazmat portion of the local plan. Determine the group’s understanding of the importance of this issue.

6. Is the current number of trained, qualified personnel within your jurisdiction sufficient to respond to this incident? If not, where will you seek support to bridge these deficiencies?

A review of the EOP should provide an indication of the number of trained and qualified personnel.

Mutual-support agreements with other local governments and state agencies should be discussed at this point.

The National Strike Force and the Army Technical Escort Unit are among the federal agencies with expertise in this area.

7. Will the city or county EOC be adequate for coordination of the response to this incident? Will a separate command center that is physically close to the incident site be required? What resources are available for outfitting this command center?

This information should be extracted from the EOP. It is assumed that an incident command system will be used.

Follow-up Questions:

How long will it take to have an EOC activated and fully operational? What are the capabilities of the center? Are these capabilities adequate to respond to an incident of the magnitude presented here?

In this scenario, the command post should be at the local EOC, so the answer will depend on how long it will take to activate the EOC and staff it appropriately and on whether the local EOC is in the affected area. If so, the use of an alternate site should be discussed.

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

The capabilities of the local EOC and an alternate EOC should be apparent from the plan review.

Note that these are not all-encompassing questions. They are only a starting point. Other issues that the jurisdiction must be capable of dealing with may arise. If topics that are more closely associated with the following two scenes are brought up, table that discussion until the appropriate time.

Instructor’s Background Information on the Incident, Scene II

The FBI attempts to establish control of the situation for crisis management, that is, a criminal investigation. At the same time, the scope of the situation makes it clear that there is also a federal role for consequence management. The Federal Emergency Management Agency (FEMA) is the federal agency designated to manage the consequence management aspect of the incident. The participants are probably not well versed in the difference between the federal definitions of crisis management and consequence management.

The presence of a nerve agent is established. Sarin is the prime suspect, although it is not confirmed by laboratory analysis. The nonpersistence of sarin means that much of the response effort takes place during the first 6 hours. Sarin dissipates after 3 or 4 hours in open areas, but it may linger in confined spaces, creating hot spots. Because the identification of the agent is unconfirmed, responders should follow response strategies associated with persistent agents.

The highways experience tremendous gridlock, and hospitals run out of medications; generally, a state of chaos persists. Consider the difficulties associated with decontaminating all of the individuals involved in the deliberate and spontaneous evacuations and those involved with the response and the consequences of failing to do so.

The large number of casualties (400 dead and 2,00 other people with severe symptoms) in this scenario quickly exhausts the limited supply of medicines such as atropine. The triage referenced in the scenario is a practice in which the emphasis is on saving the lives of as many people as possible, which means that individuals who are likely to die or for whom heroic efforts will be required to save them are lower in the treatment priority than individuals who can be more expeditiously treated.

During this session participants should recognize that federal assistance, whether it is wanted or not, is on the way. The local and state response capabilities are overwhelmed. The challenge is integrating the local response with federal and state interests and capabilities. The criminal investigation, coordinated by the FBI, has the potential to conflict with the humanitarian aspects of the response.

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

A host of federal agencies are potentially involved. They include the Environmental Protection Agency, the U.S. Department of Health and Human Services, the U.S. Department of Transportation, and most importantly, the U.S. Department of Defense because the Army has the greatest expertise in dealing with treatment and decontamination of individuals who have come into contact with chemical agents. In an actual situation it can be a real challenge to sort out all the different agencies involved in the response. A very important nonfederal agency is the American Red Cross, which offers invaluable assistance in dealing with family notification and reunification issues, as well as shelter operation.

The resources most likely required from the state National Guard are transportation, communications, and security, as well as expertise and resources related to chemical warfare.

Scene II: Chaos in the City

It is still [day of week, date of the incident in the scenario] in [city, state, of the incident in the scenario]. The weather remains calm and cloudy. The temperature is currently [high temperature, in degrees Fahrenheit, forecast for the scenario].

At 4:30 p.m. (1630 hours), the [name of the local airport] is shut down by the airport’s director of aviation following the imposition of a widespread “no-fly” area over the city by the Federal Aviation Administration. The airport will remain closed until further notice.

A preliminary situation report indicates that 400 people are dead and the unidentified hazmat has affected 2,000 other people at the [name of the mall] and surrounding area. Residents in the vicinity request directions to shelters as they evacuate. There is mounting concern and fear over the potential for additional chemical agent releases in other areas of the city. Media reports include rumors of widespread panic.

Responders continue to assess protective measures. Hot spots are identified inside the mall’s ventilation system and other confined spaces. Responders evaluate containment and decontamination strategies at these hot spots and ask if “forced ventilation” is an option. Evacuation of selected areas continues. Other measures that can be used to protect the public are evaluated. Hazmat responders debate declaring up-wind areas around the release sites safe for reentry and believe that vapor or inhalation risk is a threat in a limited area. Designated shelter locations request food, medicine, and dwelling resources and information on containment actions to prevent the spread of contamination with the chemical agent to clean areas.

Hospitals in the area report increasing cases of medical personnel exhibiting symptoms of exposure. Medical teams are unsuccessful in identi-

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

fying a chemical nerve agent, although they are certain that symptoms are caused by organophosphate poisoning. Because of the symptoms manifested by its medical personnel, [the name of the second largest medical center or hospital in the area] closes its emergency department and discourages people from coming to its facility. The [name of the second largest medical center or hospital in the area] director calls the city requesting assistance in evacuating unexposed hospital patients to another medical facility.

Area morgues are overwhelmed. Requests are made for additional resources to manage the number of bodies removed from the incident locations. The [city, county] EOC requests chemical decontamination assistance from the state and FEMA. Concerned relatives, desperate for information regarding the fate of their loved ones, call the local hospitals and cause the local telephone exchange to overload and fail.

At 5 p.m. (1700 hours), Governor [last name of the state governor] declares a state of emergency and formally requests a presidential declaration of a major disaster. Pending the president’s decision on whether to declare a disaster, the governor asks for implementation of Section 403(C) of the Stafford Act. The White House is briefed on the incident. Federal officials are notified, and federal agency regional representatives are directed to [city of the incident in the scenario; if the federal regional headquarters is within a 1-hour drive of the incident site, federal representatives may already be on site].

The [appropriate advanced forensics, academic, or hazmat laboratory in the area or region] calls the [name of state] emergency management agency (EMA) and the city to indicate that it has identified the chemical agent as sarin, the same substance used by Japanese cult members in their attack on the Tokyo subway in 1995.

A FEMA Region [region number] representative (or the federal coordinating officer) requests that the [name of state] EMA identify potential locations for the Disaster Field Office. The Disaster Field Office coordinates the overall response in accordance with the Federal Response Plan. The [name of state] EMA coordinates with the [city or county] EOC to determine the best sites for establishment of the Disaster Field Office. An advanced emergency response team is on its way from FEMA headquarters in Washington, D.C.

At 7 p.m. (1900 hours), a U.S. Department of Transportation spokesperson announces that the incident in [city, state, of incident scenario] is disrupting the national transportation network. [Provide a list of possible impacts on the national transportation network, e.g.:

if the mall is near Amtrak or other rail transportation lines, it could halt rail transportation along a major corridor;

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

if the local airport is a major transportation hub or if its closure could affect a major transportation hub, its closure could cause major disruptions of air traffic; and

the gridlock status of the Interstate highways through the area could cause disruption to Interstate traffic along major trucking corridors.]

An FBI terrorist team is dispatched to [city of the incident in the scenario] to direct crisis management operations. The team director is scheduled to meet with the [city or county] EOC and [name of state] EMA directors upon arrival. The area FBI representative arrives on site and takes control of the investigation. FBI officials suspect a terrorist group may be responsible for the incident in [city, state, of the incident in the scenario].

At 8 p.m. (2000 hours), media groups interview emergency response experts. Some theorize that the level of sophistication in the attack is an indication of international assistance. The group points to similarities between this incident and that on the Tokyo subway.

Questions, Scene II

1. Who is in charge of the incident site? How will your agency’s actions be coordinated with the actions of other agencies? What conflicts could arise from the need to simultaneously conduct extensive criminal investigatory and response functions? What conflicts may be anticipated between the overlapping federal, state, and local jurisdictions?

Explore the federal definitions of crisis management and consequence management. At the federal level, the FBI has authority over the incident site and is responsible for crisis management. FEMA has federal authority for consequence management but must conform to the direction of the FBI to protect as much of the crime scene as possible while assisting state and local authorities with providing the needed rescue and relief to protect the population. It is anticipated that most jurisdictions will follow this delineation of responsibilities.

Determine who is in charge of the local response for both consequence and crisis management.

Determine the command or management structure to be used by the jurisdiction. The incident command system has been adapted by many jurisdictions as their command structure during response operations. Explore the specifics of the local system during this discussion. A review of the EOP should have provided details on the structure of the command structure.

Conflicts will likely be related to the jurisdiction’s attempt to balance protecting evidence and protecting people. Overlapping conflicts can occur as state and federal responders arrive on scene and the transition to a unified, joint, or coordinated command or management structure begins.

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

2. What community health planning has been completed? Have privately owned hospitals, home-care agencies, long-term-care facilities, and clinics been incorporated into the EOP and included in the planning process? Has your community conducted joint exercises for this type or any type of mass-casualty situation?

The EOP review should indicate the preparedness of the community health program to address mass-casualty situations and the involvement of all local health care assets in the planning process.

Most jurisdictions should have been involved in joint mass-casualty exercises because these are an accreditation requirement for most health care organizations, especially hospitals.

Follow-up Questions:

What on-scene medical operations might be necessary?

This issue should be addressed in the community health plan as it exists. The priorities at the scene should be gross triage, transportation, and limited lifesaving efforts.

Will triage stations be established? Where will these be established?

The discussion of triage should focus on managing the flow of casualties through the community health system. The community health plan should address this issue.

What types of communications should be conducted between responders and the hospitals before the arrival of exposed victims? How will exposed patients be processed at the point of collection and the point of delivery?

Communications protocols for providing critical information should be provided within the communications section of the EOP.

Triage protocols at both collection and delivery points should also be part of the plan. Basic requirements dictate that triage be performed at both locations. This may be a good point to address the differences between standard emergency department triage and mass-casualty triage.

What medical resource shortfalls do you anticipate? What specific assistance do you need from the state and federal governments? How will these resources be integrated into the response operations?

Adequate amounts of nerve agent antidotes and sufficient numbers of medical personnel resources are the most obvious shortfalls.

State and federal plans provide for mobilization of these types of resources in disaster situations. It is important for the participants to realize that there may be a significant time delay before those resources are available.

What type of epidemiological surveillance program does your community have in place? How well defined are the linkages between the

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
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community health program and plan and your consequence management infrastructure?

Epidemiological surveillance is important in determining the number of individuals who were exposed to the nerve agent. Community health planning should account for locating within the incident area personnel who may be asymptomatic at this point.

The EOP should define the linkage between the community health program and the emergency operations management structure, and a representative of the community health agency or emergency medical service should be on the management team.

3. What immediate public relations and media concerns must be anticipated? How will these concerns be addressed? Who will serve as your jurisdiction’s spokesperson in this incident?

The Joint Information Center should be established after the arrival of state and federal assets and should serve as the source of pubic information after that point. The plan should identify who will serve as the local spokesperson before the establishment of the Joint Information Center.

Most EOPs assign the management of public affairs issues to the management team located in the EOC. Determine participants’ familiarity with public affairs procedures. Anticipating that public panic and extreme fear are likely to exist, the group should discuss how to diffuse the issue without denigrating the seriousness of the situation. Determine if the participants understand the importance of a multimedia approach and the development of themes.

In the early stages of a response, public safety messages must be disseminated quickly.

Follow-up Question:

Does the communications system meet the multilingual needs of the area?

The EOP review should identify the multilingual needs of the community and procedures for meeting those needs

4. What are the internal and external communications requirements for this response? Who is responsible for ensuring that the necessary systems are available? What problems may be anticipated?

The EOP should address internal and external communications requirements and assign responsibility for maintaining a viable system. Communications support equipment is normally located in or adjacent to the EOC.

Internal communications issues focus on the ability of jurisdictions to communicate with responders from different agencies (e.g., fire departments talking

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

to police). Determine what system is in place to facilitate such coordination or if coordination must be accomplished face to face, through dispatchers, or through the EOC.

External communications issues should focus on the procedures for providing essential information to state and federal responders and managers who are en route to the incident site.

Solutions that rely on public hard telephone lines or cellular telephone systems should be discouraged in light of the numerous demands that will be made on those systems, unless the plan review revealed that a priority override system for emergency communications is in place with local telephone service providers.

Instructor’s Background Information on the Incident, Scene III

It is now 9 hours after the initial releases. At this point, the FBI has effectively established control of the situation for crisis management purposes. The casualty figures are horrendous: 400 dead and 2,000 more people with severe symptoms. The only good news is that it is unlikely there will be many additional casualties, as it has been determined that the agent released was nonpersistent sarin. However, the threat of additional releases still looms until the terrorist group makes a formal statement to the contrary. At this point, adequate amounts of atropine have been rushed to the scene and to treatment centers.

The response has required all of the city’s emergency response forces and most of those available from the neighboring counties and other nearby cities. The stress and trauma of dealing with death on such a large scale are affecting many of the responders at the scene. Crew relief schedules have not been worked out at this time.

Decontamination is expected not to be a major issue anymore, except to foster public confidence. Cleanup and restoration of services will and should last at least 1 week.

Scene III: The Immediate Threat Wanes

It is still [day, date of the incident in the scenario] in [city, state, of the incident in the scenario]. The sun went down at [appropriate time]. The weather remains calm and cloudy. The temperature is currently [forecasted evening temperature, in degrees Fahrenheit].

The number of bodies collected overwhelms the city and surrounding morgues. Shelters are activated and provide emergency services to evacuees and displaced people. Hospitals report a noticeable drop in the number of additional victims arriving at these facilities; however, hysterical patients and asymptomatic victims continue to arrive. Mutual aid from

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

across the country continues, increasing the need for coordination of resource allocation. National FEMA and FBI representatives are on scene.

Concerned residents overload the phone emergency switchboard with requests for information regarding the whereabouts of family members. Media representatives transmit live interviews from [city of the incident]. Residents are reluctant to return to their homes, despite assurances that designated areas are safe for reentry. National attention is focused on [city of the incident]. The incident sends shock waves through the country. People nationwide avoid public places.

At 10 p.m. (2200 hours), the president issues a major disaster declaration granting FEMA authority to provide emergency response support to [city of the incident] and to conduct consequence management activities. The president, in a special statement to the nation carried live on all networks, condemns the vile act of terrorism and vows to punish the culprits. The Disaster Field Office, with its additional federal resources, will not be fully operational for another 24 hours.

It is anticipated that the [complete name of the mall where the incident occurred] and the immediate vicinity will remain closed until it is declared safe for public use (at least 1 week). The FBI directs that general, deliberate bomb searches be conducted for all major public gathering places. Although there have been no further calls from the terrorist organization, the FBI takes the statement that characterized the attack “as the first part of a coordinated terrorist attack against [the city of the incident]” during the 2:15 p.m. (1415 hours) call to [local television station listed in Scene I] very seriously.

The [name of the local airport] will reopen in the morning, but many scheduled flights into the area during the next few days are cancelled. Local businesspeople raise the specter of an economic slowdown because of concerns that their inability to resume normal operations will have a negative impact on their business activity, especially in light of the generalized searches being conducted.

Planning for site decontamination, remediation, and cleanup is initiated. Coordination of response efforts over the next 48 hours continues. Questions related to medical surveillance of response team members and the population at large, the decision to authorize population reentry, as well as public security issues, long-term medical support services, and implementation of recovery plans, are open for discussion.

Questions, Scene III

1. How will you conduct extended response operations? Are local personnel and equipment resources adequate for the extended operations that will be required?

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

The EOP should account for around-the-clock operations. Many jurisdictions plan to send a portion of the EOC staff home after the initial incident assessment reveals the need for extended operations. Determine who will be responsible for each function on multiple shifts.

Each agency will likely be overwhelmed. The real question is how much state, federal, National Guard, and mutual-aid support is needed.

2. What are your procedures for integrating state and federal resources into your management organization?

The EOP should outline the procedures for integration of state and federal resources.

State and federal assistance is supplementary to the local response; and as the Disaster Field Office is established, the federal coordinating officer and the state coordinating officer (SCO) will coordinate the activities of the state and local governments, the American Red Cross, the Salvation Army, and other disaster relief organizations.

Follow-up Questions:

How will your agency coordinate its action with other agencies (federal, state, and local) and public interest groups?

The federal coordinating officer is the primary federal coordinating authority for consequence management; the FBI handles crisis management.

With the arrival of state and federal assistance and the formation of a Joint Information Center, how will media inquiries be handled? Who in your jurisdiction is responsible for authoring media releases?

Media releases must be coordinated with the FBI, FEMA, and state and local authorities once the Joint Information Center has been established.

The EOP should provide a detailed communications and public relations plan.

3. What continuing assessments should be enacted when the cleanup phase is complete? Who will make these determinations?

Long-range health issues should be of some concern, although in the case of sarin, these will most likely be psychosomatic health issues.

4. What are the environmental concerns related to this incident?

No environmental concerns should be expected from the sarin itself; however, the local responders might identify some issues particular to their area of work.

Materials encountered or used during the response will continue to present hazards until they are neutralized.

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×
Follow-up Questions:

What steps will be taken by your agency to ensure adequate sanitation measures throughout the affected area?

The local hazmat plan should identify sanitation procedures.

What local requirements exist for reentry to an area evacuated because of a hazmat incident?

The hazmat annex to the EOP should outline procedures for reentry into an evacuated area.

After the use of chemical agents, the local emergency management team should consider the need for “safe certification,” that is, having a third-party laboratory verify that the area is free from contamination.

5. Within your jurisdiction, what psychological traumas may be anticipated? How will your agency deal with these traumas?

Many agencies have teams already designated to assist in such cases. In most instances, the teams will not have the capacity to handle the expected number of cases in an incident of this magnitude.

Discuss the availability of crisis counseling. Also, refer participants to Section 416 of the Stafford Act.

Follow-up Questions:

How will your agency participate in notification of the deaths of civilians and your colleagues? Are personnel in your agency adequately trained in the process of death notification?

Death notification is always a difficult issue. The EOP should provide guidance to managers. However, at a minimum someone in the supervisory chain should be involved with the actual notification.

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

RADIOLOGICAL SCENARIO (PLUTONIUM)

Potential Participants

Fire department

Police department or sheriff’s office

Office of Emergency Services

Public works department

Public health department

Public information officer

General counsel’s office

Medical examiner or coroner’s office

Emergency department physician

Transportation authority (port authority, airport authority, etc.)

Coordinator of volunteer organizations

Emergency medical service

Hazardous materials team

State emergency management office

Area military and local federal facilities

National Guard

U.S. Department of Energy

Federal Bureau of Investigation

Public Health Service

Centers for Disease Control and Prevention

Environmental Protection Agency

U.S. Coast Guard

Representatives of neighboring jurisdictions

The list is not intended to be either prescriptive or inclusive.

Instructor’s Background Information on the Incident, Scene I

This radiological terrorism scenario portrays an incident that local response groups and agencies can use to evaluate their coordination and response capabilities. They may also identify shortfalls in personnel or other resources that can be supplemented by state or federal sources. The scenario is intended to portray only the hypothetical technical features of a radiological terrorism incident and does not represent an actual event.

This scenario takes place in [city, state]. [Provide a brief description of the location of the radiological incident. If the building is named, then use the proper name and highlight some of the major tenants in the building.] [The location for this event should be near the middle of town in a multistory building that houses some type of hazardous materials (hazmats). A building with a propane tank on

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

its roof or stores of compressed gases is especially attractive because either will support an initiation of the radiological terrorism incident. If possible, locate the incident so that it will affect multiple transportation nodes by selecting a building that is in close proximity to a navigable river, an Interstate highway, a subway system, and an airport. Location of the incident in a building with federal or state government offices or in the area of the offices of any law enforcement authority is another desirable characteristic.]

[Provide a brief description of any local hazards that might complicate the response to the incident and its initial accompanying fires.]

[The incident should occur during a period with high levels of traffic at or on the proximate traffic nodes. Provide a description of the normal traffic patterns in the area.]

Highlights of this scene include the following:

Terrorists detonate a tank of compressed flammable gas with a device around which 600 grams of plutonium-238 is wrapped, with the radioactivity dispersed at the time of the explosion.

Responders to the scene are unaware of the presence of radioactive material for approximately 1 hour and 40 minutes.

Hazmat teams, while normally equipped with CDV-750/1500 radioactivity survey meters, may not use them unless they know of a radioactive threat.

Because of the proximity of large quantities of hazmats to the explosion, many responders are called in.

The terrorist group responsible for the detonation calls [call sign of a local news radio station] to report the explosion and radioactive release.

The local news radio station reports the explosion and the possibility of a radioactive release, causing widespread panic.

Spontaneous evacuation creates traffic chaos and overwhelms police.

The state and the National Response Center are notified of the incident.

Responders are challenged to

  • Determine what type of radioactive material was used in the attack.

  • Initiate appropriate decontamination procedures for the victims.

  • Provide appropriate protection to responders on scene.

  • Prevent the spread of the material from contaminated persons who spontaneously evacuated from the affected area.

  • Arrange for fast medical treatment for victims.

For people in the general population, national guidelines recommend dose limits of 0.5 rem/year, although international guidelines set dose

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

limits of 0.5 rem/year for short-term exposure and 0.1 rem/year for long-term exposure. Gamma radiation travels the farthest and can penetrate the entire body. It takes about 90 years for one-half of a quantity of plutonium-238 to break down to its daughter chemicals and about 24,000 years for plutonium-239 to do the same.

It should be easy to determine that this is a terrorism incident. As such, the Federal Bureau of Investigation (FBI) must be notified.

The instructor should explore how this notification will take place. This also raises many command and control issues that will be explored in further detail during Sessions II and III.

Scene I: The WMD Event Occurs

[City, state, of the incident in the scenario], [day of week, date of the incident in the scenario]. The weather forecast predicts [insert the weather forecast for the scenario; make the temperature range, amount of cloud cover, wind speed, and wind direction within the normal ranges for the date of the exercise. Wind speed and direction should be manipulated to allow the radioactive fallout to cause the desired impact on the city. Include a threat of evening rain in the forecast.]. At [time of the incident; an artificial time, not the start time of the exercise, but one selected to provide greater impact on the exposed population] it is [temperature, in degrees Fahrenheit, within the forecasted range].

At 12:35 p.m. (1235 hours), a series of loud explosions is heard at the [building or area of the incident]. A minute later, 911 receives a call from [the building tenants] and is informed that two 1,000-gallon aboveground propane storage tanks and a 3,000-gallon aboveground liquid oxygen tank (within 100 feet of the propane tanks) have exploded. Several buildings and two vehicles ignited as a result of debris from the explosions and are burning. At least one building in the area has major structural damage and is on the verge of collapse. The caller mentions that he and 4 other employees were able to evacuate the site but that 10 employees are dead and 6 are not accounted for. The caller gives the operator the address of the incident site.

The fire and police departments are called to the scene of the fire. Within minutes, firefighters, police officers, and other emergency rescue teams arrive on the scene. The fire threatens [provide a description of nearby facilities, especially hazmat sites, e.g., a nearby oil tank farm, power plant, or government office building].

Upon arrival at the scene, police evacuate the area and close the road. The initial incident commander calls in a second and third alarm due to the magnitude of the fire and the additional hazmat threat. A large black cloud develops over the area of the fire, swelling in size as the wind moves it [direction of cloud drift based on wind direction; provide direction to, not direc-

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

tion from, as wind direction is normally reported] of the incident site. By this time, emergency management team notifications are initiated and the [jurisdiction]’s Emergency Operations Center (EOC) is activated.

At 1:15 p.m. (1315 hours), a dispatcher with the police department receives a call from a news producer at [call sign of a local news radio station]. The station received a call at approximately 1 p.m. (1300 hours) from an unidentified individual claiming responsibility for setting off a nuclear device at [address of incident location and building name].

At 1:30 p.m. (1330 hours), [call sign of a local news radio station] airs a report about the explosion and announces that a terrorist group claims responsibility for planting a nuclear device at the explosion site. The newscaster notes that the police and FBI have not confirmed their report and will provide information as it becomes available. As news of the explosion and the possibility of a radioactive material release become more widely known, people around the site of the fire and in and around the downtown area panic and flee. This spontaneous evacuation causes traffic gridlock throughout the downtown area and along [Interstate and other highway designators, e.g., I-XX and Highway X].

By 2 p.m. (1400 hours), both the [city name] and the state EOC are activated. The National Response Center is notified of the explosions and the possibility of a radioactive release.

Facilitated Discussion

Purpose

This guided group discussion is designed to help participants understand the types of issues that they will encounter and the conflicts across agencies and jurisdictions that can occur in coordinating, communicating, and responding to such an incident. It also gives participants an opportunity to assess their jurisdiction’s ability to respond to such an incident.

Presentation

Guide a group discussion by asking the numbered questions on the following pages. These questions are not all inclusive; use them to develop additional questions, as necessary. Some additional questions are included should there be a need to stimulate further discussion.

Don’t forget that good facilitators speak much less than the participants. This is an assessment activity, not a formal instructional class.

Provide participants with a copy of the questions that does not include the answers to questions, additional questions, or the final note to the facilitator.

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

Be sure to touch on the following areas: direction and control, notification and activation, communications, warning and emergency public information, hazard assessment, and management of field response.

Questions, Scene I

1. How will you learn of this incident involving a weapon of mass destruction (WMD)? What internal and external notifications should you make? Are you satisfied that the current notification process is timely and adequate?

Each jurisdiction and agency should have notification procedures outlined in their emergency operations plan (EOP). The EOP review completed by the facilitator during the development portion of this activity should provide adequate detail to support facilitated discussion. The following provides general guidance:

  • In many jurisdictions, the 911 dispatcher serves as the hub of the notification system and notifies agencies and individuals.

  • In most jurisdictions, the police and fire departments have excellent internal notification systems; however, other participating agencies may not. Check this during the EOP review. During the discussion, explore if or how the police and fire departments could assist other agencies.

  • Walk participants through each step of the notification and activation process. Let them estimate their time of arrival and where they will be reporting. Do they anticipate any traffic, transportation, or communications delays that could significantly affect their response? Is there a system in place to facilitate notification when individuals are out of the office, for example, at lunch or at a meeting? How would the lower staffing normally associated with the lunch hour affect the notification process?

Follow-up Questions:

Does your jurisdiction have a policy that prevents full activation of the emergency management system when it is not needed?

The screening process should be defined in local EOPs and often relies on the local Office of Emergency Management or the EOC (if it is staffed 24 hours a day) to serve as the decision maker.

Who handles notification of state and federal authorities?

The responsibility for notification of state and federal authorities should be clearly defined in the local plan. For an incident of this magnitude, the National Response Center should be notified.

If this incident involving a WMD occurs, how long will it take responders to arrive on the scene? How long will it be before an incident command (or other management) structure is established?

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

Each agency present should provide estimates, and the participants should try to reach a consensus on the overall response time.

Explore with the participants when or what staffing level constitutes a management structure that is operational.

2. How will identification of the presence of hazardous materials occur? How will confirmation of the type of chemical hazard occur?

The EOP review should provide details on how the hazmat team identifies unknown agents. Some hazmat teams have received training on identifying radioactive materials and sources of radiation. In this scenario, it is unlikely that the local team would immediately recognize the presence of radioactive material until after the terrorists contacted the radio station. Screening for radioactive material is not part of initial assessment procedures unless there is a strong indication that radioactive materials are present (e.g., a U.S. Department of Transportation hazard placard is present or the material transportation manifest identifies the presence of radioactive materials). Once the team starts looking, it should be able to identify the material as an alpha emitter and may assume that the material is plutonium. Support laboratories in the area should have been preidentified and agreed to support emergency response operations for the jurisdiction. Additional information is provided:

Some hazmat teams have radiological survey instruments or meters that can detect gamma and beta radiation. All teams may not have alpha radiation detectors; determine the types of instruments on hand within the jurisdiction during the EOP review.

Follow-up Questions:

Will responders and hazmat units recognize the symptoms associated with exposure to radiological materials? Will responders conduct air testing or radiological surveys before responding?

The answers to these questions should be indicated through the EOP review. Here, issues such as response, protection of the population, and rescue versus self-preservation and maintenance of response capability should be addressed (i.e., responders should not be used as detectors or allowed to become victims).

Another topic for discussion at this point is the adequacy of the threat or risk assessment conducted by the local jurisdiction. The management team should be aware of the threats to the community, and their awareness should be based upon a deliberate assessment.

3. What information, equipment, and actions are required by your jurisdiction to conduct the initial assessment of the incident? How do you anticipate information to be distributed among responders?

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

Include the following items in your discussion:

  • a method to determine the size of the radioactivity dispersion device or the amount of plutonium dispersed,

  • a method to determine the location and identity of the radioactive material

  • survey meters and plume projection models,

  • an accurate weather forecast, and

  • other methods and actions as reflected in the reference material provided to the participants and developed during the review of the EOP.

4. What immediate decisions related to protective actions that should be taken should the jurisdiction make? How will they be implemented?

Decision making related to the protective actions that should be taken is a critical issue, and the participants should be allowed sufficient time to discuss the ramifications of their decisions. The whole issue of evacuation versus sheltering should be explored. The EOP should provide a framework for making such decisions. In the case of plutonium, sheltering away from the immediate site of the incident is an appropriate response. The immediate area and adjacent buildings should, however, be evacuated due to the risks associated with inhaling particles suspended in the air. Any evacuation must include the use of at least simple respiratory protection.

Allow participants to discuss the issues of decontamination and triage strategies.

Follow-up Questions:

Should the surrounding area be evacuated in this case, or will sheltering be an appropriate response?

Should the jurisdiction be concerned about the possibility of additional attacks?

This is always a possibility, and the group should discuss what changes they will have to make to manage additional incidents of either a terrorist event involving a WMD or more common emergencies (e.g., fires and auto collisions).

What medical facilities are victims and patients being sent to? What types of information should the emergency medical services units relay to the hospitals in the area to prepare them to receive potentially contaminated patients? Should any areas be quarantined?

These questions focus on the initial medical response. Allow the participants to discuss this topic, if they bring it up. If discussion of this topic is not initiated by the participants, it will be fully examined during the discussion associated with Scene II.

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

5. How will the incident site be secured to ensure that the crime scene is protected and no contaminated personnel or equipment leave the area? What access and egress control procedures should be implemented?

The EOP should provide details on contamination control procedures and crime scene protection as part of its WMD annex, if it exists. The EOP review should also provide an indication of how the jurisdiction will manage these issues.

Allow the participants in the group to discuss their security procedures and how these relate to their overall response strategy.

Access and egress control procedures should be included in the hazmat portion of the local plan. Determine the group’s understanding of the importance of this issue.

6. Is the current number of trained, qualified personnel within your jurisdiction sufficient to respond to this incident? If not, where will you seek support to bridge these deficiencies?

A review of the EOP should provide an indication of the number of trained and qualified personnel.

Mutual-support agreements with other local governments and state agencies should be discussed at this point.

The National Strike Force, the U.S. Department of Energy, and the Army Technical Escort Unit are among the federal agencies with expertise in this area.

Another excellent source of assistance to this type of incident is nuclear power plant response teams. (The Radiological Emergency Planning program is an excellent source of information for responding to an incident involving the dispersal of radioactive material.)

7. Will the city or county EOC be adequate for coordinating the response to this incident? Will a separate command center that is physically close to the incident site be required? What resources are available for outfitting this command center?

This information should be extracted from the EOP. It is assumed that an incident command system will be used.

Follow-up Questions:

How long will it take to have an EOC activated and fully operational? What are the capabilities of the center? Are these capabilities adequate to respond to an incident of the magnitude presented here?

In this scenario, the command post should be at the local EOC, so the answer will depend on how long it will take to activate the EOC and staff it appropriately

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

and if the local EOC is in the affected area. If so, the use of an alternate site should be discussed.

The capabilities of the local EOC and alternate EOC should be apparent from the plan review.

Note that these are not all-encompassing questions. They are only a starting point. Other issues that the jurisdiction must be capable of dealing with may arise. If topics that are more closely associated with the following two scenes are brought up, table that discussion until the appropriate time.

Instructor’s Background Information on the Incident, Scene II

The FBI attempts to establish control of the situation for crisis management, that is, the criminal investigation. At the same time, the scope of the situation makes it clear there is also a federal role for consequence management. The Federal Emergency Management Agency (FEMA) is the designated federal agency to manage the consequence management aspect of the incident. The participants are probably not well versed in the difference between the federal definitions of crisis management and consequence management.

The presence of radioactive material is established, but indications are that the radioactivity was dispersed via a dispersion device and is not the result of an actual nuclear detonation. Following is information on expected physical reactions to various levels of exposure:

  1. 50 rems/hour: redness of the skin

  2. 200 rems/hour: blood changes

  3. 300 rems/hour: 100 percent of the population experiences nausea, vomiting, and gastrointestinal problems

The therapeutic range of treatment is 100 to 1,000 rems. Rems represent cumulative, whole-body dosage.

FEMA indicates that after 3 hours, people in the fallout area with the highest contamination level suffer radiation sickness and that others will become ill by the 72nd hour. People in the fallout area with lower contamination levels suffer some form of radiation sickness in 3 to 6 hours. In the area of contamination most removed from the explosion, it is unlikely that anyone will suffer radiation sickness within 72 hours.

[Provide a description of how and where monitoring stations will be set up to monitor people and equipment for contamination based upon the analysis of the EOP. Many jurisdictions may rely on dated “Civil Defense” annexes based on the former Strategic Nuclear Threat.]

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

Once it is determined that contamination is an issue, focus the discussion on the next steps. Medical information indicates that removing outer clothing and shoes will, in most cases, effect a 90 to 95 percent reduction in the patient’s level of contamination. Patients should be decontaminated as soon as possible, ideally before transfer to a hospital but certainly before admission to a hospital. However, this is not always possible. Therefore, decontamination procedures should be a part of the operational plans and guides of all divisions and departments of medical facilities, not just emergency department or teams.

Because the treatment of injured, contaminated personnel may result in the contamination of almost any part of a medical facility, medical procedures must accomplish the following:

  • Minimize the degree of contamination. (How will they accomplish this?)

  • Identify and measure the extent of the contamination. (Do they have the equipment and trained personnel?)

  • Remove the contamination. (How and with which departments will this be coordinated?)

The removal of contamination is a two-part problem and includes decontamination of people as well as decontamination of equipment and facilities. The former must be started as soon as possible, even if monitoring facilities are not available. Standardized procedures of decontaminating people must be established and instituted. People must not be released before they are monitored and completely decontaminated.

Because plutonium is an alpha particle producer and does not produce a large amount of gamma radiation, harmful health effects are not likely unless the plutonium is breathed or swallowed. Most plutonium exposure occurs through breathing. Once it is breathed in, the amount remaining in the lungs depends on several things, particularly the particle size and form of the plutonium. The forms that dissolve easily may be absorbed (passed through the lungs into other parts of the body), or some may remain in the lungs. The forms that dissolve less easily are often coughed up and then swallowed. However, some of these may also remain in the lungs. The stomach poorly absorbs plutonium taken in with food or water, so most of it leaves the body in feces. Absorption of plutonium through undamaged skin is limited, but it may enter the body through wounds.

During this session participants should recognize that federal assistance, whether it is wanted or not, is on the way. The local response capabilities are overwhelmed. The challenge is integrating the local response with federal and state interests. The criminal investigation, coordinated

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

by the FBI, has the potential to conflict with the humanitarian aspects of the response.

A host of federal agencies are potentially involved. They include the Nuclear Regulatory Commission, the Environmental Protection Agency (EPA), the U.S. Department of Health and Human Services, the U.S. Department of Transportation, and the U.S. Department of Defense. The Nuclear Regulatory Commission and the U.S. Department of Defense are important because they have the greatest expertise with treatment and decontamination of individuals exposed to radioactive materials. Sorting out the agencies involved is a real challenge in an actual situation. An important nonfederal agency is the American Red Cross, which offers assistance in dealing with family notification and reunification issues, as well as assisting stranded travelers.

The resources most likely required from the state are National Guard resources for transportation and security. The National Guard should provide additional monitoring and decontamination equipment resources and operators.

Highlights of this scene include the following:

The presence of radioactive material is confirmed.

Initial readings indicate an exposure level of 60 rems/hour.

Immediate evacuation is ordered.

The FBI informs the EOC that the FBI will lead the investigation and would like to know contamination levels around the city to determine where it has safe (clean) access.

The mayor declares a local emergency and requests support from the state and federal governments.

The mayor and the governor hold a joint news conference and estimate that 50,000 people are affected by the evacuation. [This number should be adjusted on the basis of the size of the jurisdiction.]

The governor requests a presidential declaration of a federal disaster and orders the National Guard to mobilize.

Because of the exposure to radioactivity, all initial responders suffer from acute radiation exposure and many may die.

The 6 missing employees of [incident site tenant company] are still unaccounted for and are presumed to be dead; 10 employees are confirmed dead.

The president issues a disaster declaration. The Federal Response Plan and Federal Radiological Emergency Response Plan are activated.

FEMA and other federal agencies take active roles in the response.

FEMA activates the Emergency Response Team and deploys the advanced element of the Emergency Response Team and Federal Agency Support Team to the scene.

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

Some 2,500 people request medical treatment from area hospitals for radiation exposure.

Thousands of other people are reporting to hospitals claiming that they are sick or just wanting to be tested.

An initial assessment is conducted and elliptical contours are determined.

The fire at the incident site is extinguished.

Scene II: Chaos in the City

It is still [day, date of the incident in the scenario] in [city, state, of the incident in the scenario state]. The weather remains [repeat previous forecast]. The temperature is currently [forecasted midday temperature, in degrees Fahrenheit, for the scenario] with an expected high of [forecasted high temperature, in degrees Fahrenheit, for the scenario].

By 2:15 p.m. (1415 hours) the presence of a radioactive release is confirmed at the site. Readings indicate an exposure level of 60 rems/hour at the site. An immediate evacuation of the affected area is ordered. Mayor [the name of the mayor] says that [he or she] will talk with the governor soon and would like an update on evacuation, monitoring, and containment efforts as soon as possible to provide the governor with information.

On the basis of the information that it has received, the FBI believes that the device is a radioactivity dispersion device. The [location of the closest FBI office] office of the FBI notifies the city EOC that the FBI will take the lead in managing the crisis. It requests information about contamination levels around the city as soon as it is available to determine when it may access the site of the incident. The FBI wants to meet with representatives from the police department immediately to coordinate investigation efforts. It also requests that witnesses at or around the site be contacted and held for questioning by its investigators.

By 2:30 p.m. (1430 hours), the mayor declares a local emergency and asks the governor for assistance from the state and federal governments. Mayor [full name of the mayor] and Governor [full name of governor] subsequently hold a news conference. The governor indicates that [he or she] has declared a state of emergency and that an evacuation is in progress. City residents not evacuated are asked to remain indoors. Approximately 50,000 people are evacuated. [This number should be adjusted on the basis of the size of the jurisdiction participating in this training activity.]

The governor requests a presidential declaration of a federal disaster according to the Stafford Act. The governor orders the National Guard to mobilize to assist with the response effort.

Community health coordinators report that most initial emergency responders suffer from acute radiation exposure. The doctors anticipate

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

that most, if not all, will die as a result of their exposure to high dosages of radiation. The six missing employees from the incident site remain unaccounted for and are presumed dead. Only 10 deaths are confirmed at this time.

The president issues a disaster declaration, promising to bring federal resources to respond to the emergency and to bring the responsible terrorists to justice. The Federal Response Plan and Federal Radiological Emergency Response Plan are activated. FEMA and other federal agencies are asked to provide assistance to the response and recovery processes. FEMA activates the Emergency Response Team and deploys the advanced elements of the Emergency Response Team and Federal Agency Support Team to the scene. Potential sites for the Disaster Field Office (DFO) are investigated.

Area hospitals report that more than 2,500 people have requested medical treatment because they believe they have been exposed to radiation. The few hospitals not under evacuation notices are overwhelmed with thousands of people claiming to suffer from radiation sickness or just wanting radiation exposure tests. Some of them do not have the resources to conduct the required tests or carry out treatment of any type, nor are they able to institute any kind of system to monitor people coming to the hospital.

Initial assessment survey reports indicate the following:

the elliptical contour for the 60-rem/hour dose extends 1 kilometer (km) in length and 500 meters in width from the site of the incident;

the elliptical contour for the 30-rem/hour dose is 2 km in length by 1 km in width;

the elliptical contour for the 15-rem/hour dose is 5 km in length and 2 km in width; and

the elliptical contour for the 10-rem/hour dose is 8 km in length and 3 km in width.

As a result of this information, the survey teams recommend that the evacuation area be increased. The areas of contamination now include:

[Provide a bullet listing of the areas and major facilities and activities, e.g., hospitals and government buildings, contained within the contaminated area.]

[If possible, provide the participants with a map of the city with the contour lines marked on the map.]

Thanks to heroic efforts of the fire department, the fire at the incident site is extinguished.

The rush of agencies descending on the scene is causing great confusion in command, control, and reporting. Confusion also exists in prioritizing response actions versus investigatory actions, leaving many re-

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

sponders upset. The area telephone system is overloaded, leading to concerns that the system may fail. Calls to the affected areas are not going through.

Questions, Scene II

1. Who is in charge of the incident site? How will your agency’s actions be coordinated with the actions of other agencies? What conflicts could arise from the need to simultaneously conduct extensive criminal investigatory and response functions? What conflicts may be anticipated between the overlapping federal, state, and local jurisdictions?

Explore the federal definitions of crisis and consequence management. At the federal level, the FBI has authority over the incident site and is responsible for crisis management. FEMA has federal authority for consequence management, but must conform to the direction of the FBI to protect as much of the crime scene as possible while assisting local and state authorities with providing the needed rescue and relief to protect the population. It is anticipated that most jurisdictions will follow this delineation of responsibilities.

Determine who is in charge of the local response for both consequence and crisis management.

Determine the command or management structure to be used by the jurisdiction. The incident command system has been adapted by many jurisdictions as their command structure during response operations. Explore the specifics of the local system during this discussion. A review of the EOP should have provided details on the structure of the command structure.

Conflicts will likely be related to the jurisdiction’s attempt to balance the protection of evidence and the protection of people. Overlapping conflicts can occur as state and federal responders arrive on scene and the transition to a unified, joint, or coordinated command or management structure begins.

The disposal of nuclear and radioactive materials is the responsibility of the U.S. Department of Energy. The U.S. Department of Energy should be involved in the control of contamination remaining at decontamination sites and will be responsible for its subsequent disposal.

2. What community health planning has been completed? Have privately owned hospitals, home-care agencies, long-term-care facilities, and clinics been incorporated into the EOP and included in the planning process? Has your community conducted joint exercises for this type or any type of mass-casualty situation?

The EOP review should indicate the preparedness of the community health program to address mass-casualty situations and the involvement of all local health care assets in the planning process.

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

Most jurisdictions should have been involved in joint mass-casualty exercises because these are an accreditation requirement for most health care organizations, especially hospitals.

Follow-up Questions:

What on-scene medical operations might be necessary?

This issue should be addressed in the community health plan as it exists. The priorities at the scene should be gross triage, transportation, and limited lifesaving efforts.

Will triage stations be established? Where will these be established?

The discussion of triage should focus on managing the flow of casualties through the community health system. The community health plan should address this issue.

What types of communications should be conducted between responders and the hospitals before the arrival of exposed victims? How will exposed patients be processed at point of collection and point of delivery?

Communications protocols for providing critical information should be provided within the communications section of the EOP.

Triage protocols at both collection and delivery points should also be part of the plan. Basic requirements dictate that triage be performed at both locations. This may be a good point to address the differences between standard emergency department triage and mass-casualty triage.

What specific assistance do you need from the state and federal governments? How will these resources be integrated into the response operations?

State and federal plans provide for mobilizing these types of resources in disaster situations. It is important for the group to realize that there may be a significant time delay before those resources are available.

What type of epidemiological surveillance program does your community have in place? How well defined are the linkages between the community health program and plan and your consequence management infrastructure?

Epidemiological surveillance is important in determining the number of individuals who were exposed to the radiological material. Community health planning should account for locating within the incident area personnel who may be asymptomatic at this point, especially in light of the potential long-term health effects.

The community should consider establishing a database to track the health of those members of the community, including responders, who may have been exposed to plutonium.

The EOP should define the linkage between the community health program

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

and the emergency operations management structure, and a representative of the community health agency or emergency medical services should be on the management team.

3. What immediate public relations and media concerns must be anticipated? How will these concerns be addressed? Who will serve as your jurisdiction’s spokesperson in this incident?

The Joint Information Center should be established after the arrival of state and federal assets and should serve as the source of pubic information after that point. The plan should identify who will serve as the local spokesperson before the establishment of the Joint Information Center.

Most EOPs assign the management of public affairs issues to the management team located in the EOC. Determine participants’ familiarity with public affairs procedures. Anticipating that public panic and extreme fear are likely to exist, the group should discuss how to diffuse the issue without denigrating the seriousness of the situation. Determine if the participants understand the importance of a multimedia approach and the development of themes.

In the early stages of a response, public safety messages must be disseminated quickly.

Follow-up Question:

Does the communications system meet the multilingual needs of the area?

The EOP review should identify the multilingual needs of the community and procedures for meeting those needs.

4. What are the internal and external communications requirements for this response? Who is responsible for ensuring that the necessary systems are available? What problems may be anticipated?

The EOP should address internal and external communications requirements and assign responsibility for maintaining a viable system. Communications support equipment is normally located in or adjacent to the EOC.

Internal communications issues focus on the ability of jurisdictions to communicate with responders from different agencies (e.g., fire departments talking to police). Determine what system is in place to facilitate such coordination or if coordination must be accomplished face to face, through dispatchers, or through the EOC.

External communications issues should focus on the procedures for providing essential information to state and federal responders and managers who are en route to the incident site.

Solutions that rely on public hard telephone lines or cellular telephone systems should be discouraged in light of the numerous demands that will be made

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

on those systems, unless the plan review revealed that a priority override system for emergency communications is in place with local telephone service providers.

Instructor’s Background Information on the Incident, Scene III

With the downpour of rain, much of the radioactive particles are washed into the soil and down the [appropriate name] River, which flows from [direction of river flow, e.g., south to north, if a river is in the area]. [If there is not a river in the area, describe the watershed and provide an indication of the potential areas that will be affected by the runoff.] Farmers in [provide names of locations in the area potentially affected by the runoff of radioactive particles] use the irrigation water that has its source in this area.

Sanitation is a major issue at shelters and hospitals. The safety and health of patients who were in the hospitals for other reasons are compromised by the influx of patients and material contaminated with radioactive fallout.

Highlights of this scene include the following:

It starts getting dark and rainy.

The National Guard arrives and begins to take up positions throughout the city.

Hospitals request assistance with transporting overflow patients to other facilities.

Evacuated hospitals also request transportation and other logistical support.

Disposal of contaminated equipment and other material becomes a major issue.

Farmers downstream of the city are concerned about radiation fallout and its effect on their water supplies.

The public is provided with information on radiation exposure and fallout.

Reports indicate that approximately 3,800 people suffer radiation sickness or were exposed and require decontamination.

The DFO is situated, staffed, and in full operation.

The Joint Information Center is inundated with calls from the media about the response effort and the lack of information being provided to them.

Scene III: The Immediate Threat Wanes

It is 7:45 p.m. (1945 hours) on [day, date of the incident in the scenario ] in [city, state, of the incident in the scenario ]. The sun sets at [appropriate time]. Rain starts to fall. The temperature is currently [forecasted temperature, in

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

degrees Fahrenheit, at the end of the day]. [Since it is now evening, adjust the background description to the past tense if the sun has already set.]

The rain and darkness complicate the response efforts. By 7:50 p.m. (1950 hours), members of the National Guard arrive and take up positions in and around downtown to assist the police with their duties and the decontamination and containment efforts. The American Red Cross offers assistance in transporting food, water, medications, and other resources to shelter locations and wherever else they are needed. Officials from the EPA contact the [city or jurisdiction] Public Works Department, [city or jurisdiction] Safety Department, and the [state] Department of Safety to coordinate efforts to monitor radiological contamination that may migrate into drinking water sources, surrounding lakes, rivers, and soil.

Several hospitals request assistance with transporting patients to other hospitals because of inadequate resources. They also request immediate assistance with monitoring incoming patients and decontamination procedures or they will be forced to turn additional patients away. Proper disposal of contaminated equipment and other material accumulating at the hospitals becomes a concern. The community health spokesperson [or some other official, determined on the basis of an Office of Emergency Preparedness review] holds a new conference at which he or she provides the public information regarding the effects of radiation under the current situation and encourages people to stay indoors. This conference is not coordinated with the Joint Information Center.

Agricultural, health, and safety officials from [area, e.g., the state or surrounding counties] and [surrounding states] are concerned that radiation fallout in the surrounding watershed, used for irrigation and other water supplies, will affect livestock and crops. Those calls persist as politicians from those areas pressure the EPA and the U.S. Department of Agricul-ture to certify the quality of the water from the region.

By 10:30 p.m. (2230 hours), updated reports of casualties filter in from area hospitals, shelters, and residences. It is reported that approximately 3,800 people either suffer radiation sickness or were exposed to radiation and still require decontamination and advanced medical treatment.

U.S. Department of Defense, U.S. Department of Energy, and EPA officials express concern about the possibility of a large number of people leaving the area before being monitored for contamination. There is also concern that many contaminated vehicles traveled to other jurisdictions.

By 4 a.m. (0400 hours), the DFO is in full operation. The media inundates the Joint Information Center with calls questioning the adequacy of the response effort and the lack of information provided to them and the public by state and local authorities.

The FBI requests protective equipment to access the site of the explo-

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

sion to look for clues and extract the remains of the radioactivity dispersion device.

Questions, Scene III

1. How will you conduct extended response operations? Are local personnel and equipment resources adequate for the extended operations that will be required?

The EOP should account for around-the-clock operations. Many jurisdictions plan to send a portion of the EOC staff home after the initial incident assessment reveals the need for extended operations. Determine who will be responsible for each function on multiple shifts.

Each agency will likely be overwhelmed. The real questions are how much state, federal, National Guard, and mutual-aid support is needed.

2. What are your procedures for integrating state and federal resources into your management organization?

The EOP should outline the procedures for state and federal integration.

State and federal assistance is supplementary to the local response; and as the DFO is established the federal coordinating officer and state coordinating officer will coordinate the activities of the state and local governments, the American Red Cross, the Salvation Army, and other disaster relief organizations.

Follow-up Questions:

How will your agency coordinate its action with other agencies (federal, state, and local) and public interest groups?

The federal coordination officer is the primary federal coordinating authority for consequence management; the FBI handles crisis management.

With the arrival of state and federal assistance and the formation of a Joint Information Center, how will media inquiries be handled? Who in your jurisdiction is responsible for authoring media releases?

Media releases must be coordinated with the FBI, FEMA, and state and local authorities once the Joint Information Center has been established.

The EOP should provide a detailed communications and public relations plan.

3. What continuing assessments should be enacted when the cleanup phase is complete? Who will make these determinations?

Long-range health issues are of great concern.

Hazmat sites, especially decontamination stations, should be examined periodically until it is determined that there is no longer an environmental hazard.

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
×

The EOP should provide an overview of how continuing assessments and long-term monitoring are accomplished; allow the participants in the group to discuss their areas of concern and propose priorities.

4. What are the environmental concerns related to this incident?

There are numerous concerns related to plutonium, for example, it is a heavy metal and is toxic in its own right beyond the long-term effects on humans, animals, and other forms of life. The local responders might also identify some issues particular to their area.

Materials used during the response will continue to present hazards until they are neutralized.

Follow-up Questions:

What steps will be taken by your agency to ensure adequate sanitation measures throughout the affected area?

The local hazmat plan should identify sanitation procedures related to radiological operations.

What local requirements exist for reentry to an evacuated area due to a hazmat incident?

The hazmat annex to the EOP should outline reentry procedures.

After the release of radioactive materials, the local emergency management team should consider the need for safe certification, that is, having a third-party laboratory verify that the area is free from contamination.

5. Within your jurisdiction, what psychological traumas may be anticipated? How will your agency deal with these traumas?

Many agencies have teams already designated to assist in such cases. In most instances, the teams will not have the capacity to handle the expected number of cases in an incident of this magnitude.

Discuss the availability of crisis counseling. Also, refer participants to Section 416 of the Stafford Act.

Follow-up Questions:

How will your agency participate in notification of the deaths of civilians and your colleagues? Are personnel in your agency adequately trained in the process of death notification?

Death notification is always a difficult issue. The EOP should provide guidance to managers. However, at a minimum someone in the supervisory chain should be involved with the actual notification.

Suggested Citation:"Appendix F Scenarios and Discussion Materials for Use on Site Visits." Institute of Medicine. 2002. Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program. Washington, DC: The National Academies Press. doi: 10.17226/10412.
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The Metropolitan Medical Response System (MMRS) program of the U. S. Department of Health and Human Services (DHHS) provides funds to major U. S. cities to help them develop plans for coping with the health and medical consequences of a terrorist attack with chemical, biological, or radiological (CBR) agents. DHHS asked the Institute of Medicine (IOM) to assist in assessing the effectiveness of the MMRS program by developing appropriate evaluation methods, tools, and processes to assess both its own management of the program and local preparedness in the cities that have participated in the program. This book provides the managers of the MMRS program and others concerned about local capabilities to cope with CBR terrorism with three evaluation tools and a three-part assessment method. The tools are a questionnaire survey eliciting feedback about the management of the MMRS program, a table of preparedness indicators for 23 essential response capabilities, and a set of three scenarios and related questions for group discussion. The assessment method described integrates document inspection, a site visit by a team of expert peer reviewers, and observations at community exercises and drills.

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