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APPENDIX E

Excerpts from the Metropolitan Medical Strike Team Operational System Description *

*Source: Metropolitan Medical Strike Team Operational System Description. Rockville, MD: Office of Emergency Preparedness, U.S. Public Health Service, 1997.



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Improving Civilian Medical Response to Chemical or Biological Terrorist Incidents: Interim Report on Current Capabilities APPENDIX E Excerpts from the Metropolitan Medical Strike Team Operational System Description * *Source: Metropolitan Medical Strike Team Operational System Description. Rockville, MD: Office of Emergency Preparedness, U.S. Public Health Service, 1997.

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Improving Civilian Medical Response to Chemical or Biological Terrorist Incidents: Interim Report on Current Capabilities METROPOLITAN MEDICAL STRIKE TEAM MISSION, CONCEPT OF OPERATIONS, AND TEAM ORGANIZATION Mission Statement It is the mission of the MMST to respond to, provide support for, and provide assistance to local and regional jurisdictions to effectively address responder safety issues, incident management, and public health consequences of NBC incidents that result from accidental or deliberate acts. This support and assistance includes providing planning and training to response personnel prior to an NBC incident, identification of the offending substance via available technology, off-site management consultation service, and, where needed, response to the scene or secondary site to assist with incident management and medical care during an NBC incident. These activities will be conducted in collaboration with and supported by Federal, State, and local authorities. Scope of Operations The MMST response, assistance, and support includes: Responding at the request of local and/or regional jurisdictions; Providing medical management and/or medical assistance and support of NBC incidents; Providing training and response planning assistance to response personnel, prior to NBC incidents; Providing technical assistance in the identification of NBC agent or agents and medical intelligence regarding NBC incidents; and Supporting coordination and interaction With designated local, regional, State, and Federal NBC incident response authorities.

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Improving Civilian Medical Response to Chemical or Biological Terrorist Incidents: Interim Report on Current Capabilities Concept of Operations The MMST is a technical-professional team that provides assistance to local and regional responders. This assistance may be by way of a response to an incident site or may be by way of consultation by telephone. If a response is required, the team will be on site within 90 minutes of notification. The MMST, when activated, operates in a Federal status. Once on site, the Task Force leader will report directly to the incident commander to advise of the team's arrival and to be briefed on what has occurred and what action plans are currently in place. If no formal incident command has been established, the Task Force leader will take the necessary steps to begin establishing an incident command system. Since it is not the purpose of the team to take control of the incident, the team leader will coordinate with the existing incident commander to determine how to best deploy team resources. The team will then be deployed into operational support sectors that may directly contribute to successful mission completion. These sectors can include: Hospital/Public Health Coordination—Coordination with local public health officials and hospitals that includes professional medical guidance on agent identification, mass triage and decontamination, victim intake, and treatment for specific agents. Medical Treatment/Management—Direct medical intervention in NBC incident consequences. Incident Command Liaison—Liaison and coordination with the local incident commander that includes advising on technical and medical professional issues, establishing an Incident Command System (ICS) if none has been established, and establishing and deploying MMST resources into the existing ICS. Decontamination—Coordination with the existing ICS to establish mass decontamination facilities. Pharmacology—Maintenance, distribution, and administration of appropriate medications for NBC incidents maintaining an inventory of medications and monitoring the medications' shelf life to ensure they remain current. Communications—Maintenance and inventory of communications and coordination with the local ICS to establish common communications capabilities.

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Improving Civilian Medical Response to Chemical or Biological Terrorist Incidents: Interim Report on Current Capabilities Public Information Officer (PIO)/Media Relations—Coordination with the local PIO to establish information parameters and determine the appropriate information releases to avert further casualties due to mass hysteria. Law Enforcement Coordination (Intelligence/Security)—Coordination with local law enforcement officials to brief them on the potential impacts of the incident and courses of action to take. As soon as practical, the Task Force leader will begin assessing the situation by identifying the probable agent involved by victim symptomology, clinical examination, and testing and environmental sampling. Each sector officer will ensure that his/her sector personnel are engaged in sector responsibilities and have been established in a personnel accountability process. Local Plan Coordination Local jurisdictions should have disaster plans that depict what their agencies' roles and responsibilities are in disaster situations; however, many may not have addressed the specific topic of NBC terrorist incidents. Nonetheless, first responders should establish ICSs into which the MMST can assimilate and begin operating. Capability It should be recognized that most, if not all, NBC incidents will probably not be initially recognized for what they actually are, and local providers will be requested due to the large number of victims and other unusual circumstances surrounding the incident; therefore, until the MMST can be activated, local providers will be the primary line of defense and action. Notification and activation will most likely result from actions in the community at large. The MMST will have the capability of supplementing local responders, including HAZMAT teams. This will include site entry, agent determination, drug administration, victim retrieval and treatment, and victim and rescuer decontamination procedures. Organization The MMST is organized into one or more Task Forces, each consisting of 43 personnel. The MMST is organizationally directed by a Program Management

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Improving Civilian Medical Response to Chemical or Biological Terrorist Incidents: Interim Report on Current Capabilities Team (PMT) consisting of a Program Director and one or more Assistant Directors. An organizational figure and response concept figure are included at the end of this section. Task Force Position Roles and Responsibilities Task Force Leader. The MMST Task Force Leader should come from the segment of the community that has primary responsibility for emergency response for this and similar type incidents. In most jurisdictions this will be a representative of the fire service, but that will not necessarily always be the case. Safety Officer. This person would most likely be a fire service representative who has had exposure to or served as a departmental safety officer or who has had responsibility for establishing safety policy. This person will ensure that decontamination operations are in place, safety zones are established, site safety plans are developed and in place, and evacuation parameters are established and in place. Medical Information - Research Sector. This sector is directed by a physician who oversees the medical operation of NBC incidents and coordinates the following functions: Product/agent identification Public health issues PIO liaison Cleanup resources Personnel for this sector include a toxicologist and pubic health specialist. Field Medical Operations. This sector is directed by a HAZMAT technician, usually a fire officer who oversees the following functions: Medical operations Reconnaissance Decontamination

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Improving Civilian Medical Response to Chemical or Biological Terrorist Incidents: Interim Report on Current Capabilities Transportation Personnel for this sector include Hazardous Materials (HAZMAT) technicians, and Emergency Medical Technician/Paramedics (EMT/Ps). Hospital Operations. This sector is directed by a physician who oversees the following functions: Hospital communication/liaison Medical information sharing Patient disposition tracking Hospital resupply and pharmacology Personnel for this sector include an Emergency Room (ER) Registered Nurse (RN). Law Enforcement Sector. This sector is directed by a law enforcement officer, usually of sergeant rank or higher who oversees the following functions: Intelligence Police logistics Team/scene security Evidence control Personnel for this section include police officers with expertise in these functional areas. This configuration allows the unit to be split into two field response teams. Each member should be cross-trained in two or more roles. At least four persons per deployment should be trained in Critical Incident and Stress Debriefing (CISD). Logistics Sector. This sector is directed by a fire service representative with experience in supply and equipment maintenance.

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Improving Civilian Medical Response to Chemical or Biological Terrorist Incidents: Interim Report on Current Capabilities

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Improving Civilian Medical Response to Chemical or Biological Terrorist Incidents: Interim Report on Current Capabilities Plan Maintenance Requirements It is the responsibility of the sponsoring jurisdiction to keep the U.S. Public Health Service/Office of Emergency Preparedness (USPHS/OEP) apprised of any changes that would affect the MMST's status. Changes should be reported in writing to the Director, Office of Emergency Preparedness, U.S. Public Health Service, 5600 Fishers Lane, Rockville, MD 20857. It is also the responsibility of the sponsoring jurisdiction(s) to maintain this plan. It will be reviewed annually by the team members for revisions. Once the needed revisions are made, they will be distributed to plan holders.

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Improving Civilian Medical Response to Chemical or Biological Terrorist Incidents: Interim Report on Current Capabilities METROPOLITAN MEDICAL STRIKE TEAM TEAM ACTIVATION There are different levels of Team Activation depending upon the magnitude of the incident and the specific type of incident, i.e., nuclear, biological, or chemical (NBC). The MMST, when activiated, operates in a Federal status. I. INTRODUCTION There are three types of activities where the Metropolitan Medical Strike Team (MMST) may become involved in an NBC incident. Deployment. There are two types of deployment of MMST assets: Emergency Deployment involves the limited or substantial release with no warning of NBC materials resulting in injuries or death. Deliberate Deployment involves the confirmed or suspected presence of NBC materials without an actual release. A deliberate deployment could also be the result of a scheduled field training exercise of MMST assets or a determination by the MMST Director that the deployment of certain or all MMST components may be advisable. Emergency Consultation involves detecting medical symptoms or other indicators when a large number of patients are entered into the Public Health System with symptoms that may be associated with exposure to NBC materials and providing advice to public health entities after a release. Technical Assistance involves providing advice to law enforcement or other entities that through intelligence gathering or other means have received a warning or threat to release NBC materials in a given area.

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Improving Civilian Medical Response to Chemical or Biological Terrorist Incidents: Interim Report on Current Capabilities IV. FIELD OPERATIONS GUIDE The United States Public Health Service Metropolitan Medical Strike Team (USPHS MMST) Field Operations Guide (FOG) has been developed to assist Strike Team members during training and on mission assignments. The FOG is a compilation and summary of important strategic and tactical information. Position description summaries and complete operational checklists are outlined for each of the positions that make up the Strike Team. Use of, and adherence to, the FOG will ensure optimum personal and Strike Team performance standardization of activities and procedures between Strike Teams and will promote safe and effective search and rescue operations. INTRODUCTION This document outlines the current tactical capabilities and general strategies that should constitute a foundation for productive nuclear, biological, or chemical (NBC) incident mitigation. All Strike Team personnel should have a solid understanding of these guidelines. MMST personnel must tailor the general strategy and tactics to fit the specific situation encountered. It is incumbent on the Task Force Leader (TFL) and sector officers to implement coordinated tactics and strategy, collect and collate related information, and develop an effective overall task force plan. Tactical Operations The most effective strategies will blend all viable tactical capabilities into a logical plan of operation. The following general tactical operations are defined: Reconnaissance It is critical in NBC incidents that the agent or material be identified as soon as possible to begin early, comprehensive medical intervention. Victims signs and symptomology can serve as early indicators of the type of agent involved. As an example, a nerve agent produces

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Improving Civilian Medical Response to Chemical or Biological Terrorist Incidents: Interim Report on Current Capabilities convulsions, miosis, and uncontrollable defecation and urination, whereas phosgene may produce irritation and redness of the skin, increased presence of blood in the eyes, and possible ultimate cardiac collapse. Presence of a haze, mist in the air, or unusual odors suggests the presence of a chemical agent. Using the appropriate detection and monitoring equipment, team personnel must determine the extent of the agent or material envelope in order to establish hot, warm, and cold zones. Isolation Once an area has been identified as affected, that area(s) needs to be isolated into the three primary zones: hot, warm, and cold. Unaffected persons outside the affected area must be prevented from entering the warm or hot zones. Consideration must be given to wind direction and speed when establishing critical zones and determining the agent envelope. Affected persons inside the hot and warm zones (victims) must be triaged according to the severity of their exposure to the agent or material. Obtaining agent or material samples will expedite identification. However, caution should be used if the dissemination device is discovered because it may contain a secondary explosive device. Work Period and Rehabilitation It is extremely important that all team members be cognizant of the weather conditions when operating at NBC incident sites. The protection needed to maintain a safe personal environment can also work against the member by elevating the ambient temperatures to dangerous levels, particularly if the member must remain in an encapsulated garment for long periods of time.

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Improving Civilian Medical Response to Chemical or Biological Terrorist Incidents: Interim Report on Current Capabilities Entry and decon teams must have vital signs recorded prior to entry and upon exit from the decon area. Team members working in any form of personal protective equipment (PPE) will work strictly within the timeframe assigned by the task force Safety Officer for the incident. This decision will take into account environmental considerations (temperature, humidity, barometric pressure, etc.), dangers involved, and personnel resources available. Members who have completed their assignment and are exiting the decon area (entry team or decon team) will immediately report to the rehab area for rest, observation, and post assignment examination. The rehab area will have the refreshments appropriate to maintain team members' health. Resources permitting, members will not be reassigned to an entry team or decon team until a minimum 60-minute rest period has elapsed. Protective Clothing Having the appropriate protective clothing is essential for the safety of team members operating at an NBC incident site. Unless otherwise warranted, entry team members will wear only level “A” encapsulated suit ensembles with 4-hour, self-contained breathing apparatus (SCBA) and appropriate boots, gloves, and helmets. Team members operating in the decon area will have the appropriate level of protection as determined by the Safety Officer (usually one level below that used by the entry team). Members operating in the Command Post area will wear helmets and command vests that denote their team position and have immediately available their “GO” kits, which contain masks, suits, gloves, and nerve agent antidote.

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Improving Civilian Medical Response to Chemical or Biological Terrorist Incidents: Interim Report on Current Capabilities Communications Effective communication is vital to the safe and successful operations of a Strike Team assigned to a mission. The following procedures are identified to promote standardization: Task Force Designations Communications Procedures Between Team Members Task Force Designations Each task force will be identified by a unique radio call sign. The call sign will incorporate the State of origin of the Strike Team and a number to differentiate each Strike Team from that State. For example, DC Strike Team One will be used to identify the first Strike Team developed for the USPHS MMST concept. This would be denoted as DC-1 for written correspondence. The following Strike Team designations will identify the currently accepted Strike Teams sponsored by the listed organizations: – DC-1 Metropolitan Washington Area Council of Governments – GA-1 Atlanta Area Police and Fire Departments Communications Procedures Team members (except entry teams) will communicate on the operational channel assigned upon arrival at the incident site. Entry teams, if used, will operate on the operational channel assigned them prior to making entries. It is permissible for members to monitor the entry team channel, but they will not transmit on that channel(s) unless there is an emergency situation that requires that the entry team be immediately notified. That notification should originate from the entry team sector leader, but may originate from anyone detecting the emergency situation.

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Improving Civilian Medical Response to Chemical or Biological Terrorist Incidents: Interim Report on Current Capabilities Entry teams will communicate directly with the Hazardous Materials (HAZMAT) Officer who will communicate with the Field Medical Operations Officer on the primary operational channel. The Safety Officer can monitor the channels as he/she feels appropriate for the specific situation, but will use the primary operational channel for routine interteam communications. Sector leaders will use the primary operational channel for routine interteam communications. The TFL and/or Assistant Task Force Leader (ATFL) will operate on the primary operational channel for communications with team members. The TFL and/or ATFL will operate on the local jurisdiction's frequency (patched in) when it is necessary to communicate electronically with the Incident Commander (IC) or Command Post. The Medical-Information Research Sector (MIRS) will communicate within the team on the primary operational channel and will use cellular phones/fax for communications to organizations and facilities outside the incident geographic area (e.g., Centers for Disease Control (CDC), local area poison control centers, etc.). The Hospital Operations Sector will communicate within the team on the primary operational channel and will use cellular phone/fax for communications to medical facilities within the incident geographic area (e.g., local hospitals, medical facilities, etc.). Medical Management The task force is organized, staffed, and equipped to provide the best possible pre-hospital and emergency medical care throughout the course of an incident and especially on scene. Task force personnel are responsible for minimizing health risks and incidence of Critical Incident Stress (CIS) syndrome. Medical personnel are responsible for providing the earliest possible medical intervention for fast responders and civilian victims of NBC

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Improving Civilian Medical Response to Chemical or Biological Terrorist Incidents: Interim Report on Current Capabilities incidents through early identification of the agent type and proper administration of the appropriate antidote(s) and other pharmaceuticals as necessary. Personnel must be cautious about utilizing persons offering to assist in medical management who claim to be physicians, nurses, or other medical practitioners and who cannot substantiate their claims or provide adequate credentials. Practitioners who provide credentials indicating that they have a medical background should be assigned responsibilities only in the cold (support) zone commensurate with their area of medical expertise and in an area working with a known team member. Treatment Priorities The treatment priorities for medical personnel (including Emergency Medical Services (EMS) members) are: – First, Strike Team personnel and sipport staff – Second, local response personnel who become ill or injured – Third, victims directly encountered by the Strike Team – Fourthly, other injured/affected persons as practical It is not the intent of the Field Medical Operations Sector and Hospital Operations Sector to be a free-standing medical resource at incident seem. However, they are part of the first line of intervention in a chain of care that stretches to the local hospital medical system. Triage Triage is the process of doing the most good for the most victims. In NBC incidents, depending upon the purity of the agent, there may be few viable victims within the hot zone and increasing numbers of viable victims near the outer perimeter where the agent is less concentrated. Victims should be triaged using the Strike Team triage protocol listed below.

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Improving Civilian Medical Response to Chemical or Biological Terrorist Incidents: Interim Report on Current Capabilities Patients will be classified as: – Priority one, exposed but not symptomatic – Priority two, exposed, symptomatic, but salvageable if medical care is rendered within 15 minutes – Priority three, exposed, symptomatic, and will require extensive medical intervention to save The initial triage priority will be indicated by marking the number indicating the priority on the patient's forehead with a felt pen. A triage tag indicating the patient's priority is to be used as soon as possible. Decontamination It is extremely important that victims of NBC incidents be, at minimum, grossly decontaminated prior to being transported to medical facilities. Additional decontamination will be conducted as time and resources allow. The degree of medical decon that has been performed and what solution was used must be noted on patient care forms (triage tags), which are attached to victims prior to transport. Definitive decon (a more intensive scrubbing/cleansing of patients) may have to be completed at receiving medical facilities; this should also be noted on the triage tags. Emergency decontamination procedures will be immediately initiated when MMST personnel are injured and/or have a PPE failure. Appropriate basic medical care will be initiated during decon and continued in the treatment sector. A rapid assessment will be initiated by a decon team member and the findings immediately reported to the HAZMAT Officer and Field Medical Operations Officer.

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Improving Civilian Medical Response to Chemical or Biological Terrorist Incidents: Interim Report on Current Capabilities Treatment Rapid BTLS assessment will be conducted on all victims. Medical intervention will be initiated following the MMST protocols found in Appendix I. Particular medical attention is to be paid to airway/respiratory support and cardiovascular support. Medical care will address the supportive needs of each patient and the specific treatment will be initiated when the agent is identified. On-site treatment may include care for injuries sustained as a result of explosions and/or falls. Consideration must be given to the medical and logistical implications of multiple doses of an antidote (ex., atropine) being given to a single victim, thereby reducing the total number of patients that can be treated effectively. The Poison Control Center should be immediately notified of patient problems being seen and used as a resource for product identification and determining treatment regimens not covered by MMST protocols. Transportation Transportation of victims who are unconscious must be by an emergency vehicle capable of continuous treatment and emergency response to the medical facility. Large numbers of victims who are minimally affected or who are suspected of having psychosomatic symptoms can be transported by public transportation vehicles staffed with an appropriate number of local EMS personnel. These victims would normally be triaged as being among the last victims to be transported. MMST personnel arranging for transportation must keep in mind that vehicles used for transport may become contaminated; that fact should be borne in mind when obtaining public transport vehicles.

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Improving Civilian Medical Response to Chemical or Biological Terrorist Incidents: Interim Report on Current Capabilities Vehicles and personnel used for transport that become contaminated must be decontaminated before returning to service. Casualty Collection Center (CCC) If delay is encountered in transporting decontaminated victims, consideration will be given to establishing a CCC to continue medical treatment until transportation for victims is completed. This area should be located as far away from the main operating area of the incident as is possible and adjacent to the transportation sector. Staffing will be the shared responsibility of the MMST and local jurisdiction. Medical care initiated will be what is necessary to stabilize the patient condition pending transportation. Equipment for the CCC will come primarily from the local jurisdiction. MMST equipment will be used only if absolutely necessary. Deceased individuals will be separated from the living. Hospital Support It is likely that in an NBC incident of significant proportions, the local hospital system will be overwhelmed with casualties. It may be necessary for the Hospital Support Sector to contact hospitals by phone/fax to give advice on decon procedures for victims who self-refer, agent treatment protocols, and other information as requested by medical facilities. If the TFL determines that there is benefit in providing MMST personnel to local hospitals to assist in the management of incident patients, consideration should be given to the recall of local off-duty emergency medical technicians (EMTs) and paramedics as well as MMST members.

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Improving Civilian Medical Response to Chemical or Biological Terrorist Incidents: Interim Report on Current Capabilities MMST members can provide assistance to medical facilities in the following areas: – Patient tracking – Decon procedures for self-referrals – Vital-sign monitoring – Triage – Medical management – Communications and coordination between the incident site and hospital Became the pharmaceuticals used for NBC incidents are not normally stocked in adequate quantities, it may be necessary to access additional supplies from manufacturers, local Veteran's Administration (VA) hospitals, or the USPHS. Once the pharmaceuticals have been accessed, redistribution can be coordinated at the incident site by the Hospital Operations Sector assisted by the Logistics Sector. Redistribution of pharmaceuticals to medical facilities is to be accomplished by the use of fire, law enforcement, or hospital personnel.

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