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



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

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

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program 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.

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

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program 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.

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

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program 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.

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program 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.

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program 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.

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program 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-

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

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

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program 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.

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

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program 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-

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program 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.

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

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System 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. 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

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

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program 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-

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program 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.

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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program 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.