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Hospital Emergency Response Hospital Emergency Response Training (HERT) for Mass Casualty Training (HERT) for Mass Casualty Incidents (MCI) Train-the-Trainer Incidents (MCI) Train-the-Trainer
Course Course
Course Code: B461Course Code: B461
DHS/NTCDHS/NTC B461 CourseB461 Course 22
HERT FOR MCIHERT FOR MCI
Hospital Emergency Response Training (HERT) for Mass Hospital Emergency Response Training (HERT) for Mass Casualty Incidents (MCI) Train-the-Trainer, B461 CourseCasualty Incidents (MCI) Train-the-Trainer, B461 Course
Resident Offering at Noble Training Center, Anniston, Resident Offering at Noble Training Center, Anniston, AlabamaAlabama
4.0 Days4.0 Days Special offerings for hospital emergency departments, Special offerings for hospital emergency departments,
administration, and staff personnel administration, and staff personnel Prerequisites:Prerequisites:
IS-195, Basic ICSIS-195, Basic ICS IS-346, An Orientation to Hazardous Materials for Medical IS-346, An Orientation to Hazardous Materials for Medical
PersonnelPersonnel
DHS/NTCDHS/NTC B461 CourseB461 Course 33
What HERT for MCI is Not?What HERT for MCI is Not?
Not a HazMat Course. Need additional training under:Not a HazMat Course. Need additional training under: OSHA’s Hazardous Waste Operations and Emergency OSHA’s Hazardous Waste Operations and Emergency
Response, 29 CFR 1910.120, par (q), 1990Response, 29 CFR 1910.120, par (q), 1990 OSHA 3152 Hospital and Community Emergency Response – OSHA 3152 Hospital and Community Emergency Response –
What You Need to Know, 1997What You Need to Know, 1997 OSHA’s Best Practices for Hospital-Based First Receivers of OSHA’s Best Practices for Hospital-Based First Receivers of
Victims from Mass Casualty Incidents Involving Hazardous Victims from Mass Casualty Incidents Involving Hazardous Substance Releases, 2004Substance Releases, 2004
Department of Health and Human Services, CDC Department of Health and Human Services, CDC Recommendations for Civilian Communities Near Chemical Recommendations for Civilian Communities Near Chemical Weapons Depots: Guidelines for Medical Preparedness, 1995Weapons Depots: Guidelines for Medical Preparedness, 1995
USACHPPM, Technical Guide 275, PPE for Military MTF USACHPPM, Technical Guide 275, PPE for Military MTF Personnel Handling Casualties from WMD and Terrorist Events, Personnel Handling Casualties from WMD and Terrorist Events, 20032003
DHS/NTCDHS/NTC B461 CourseB461 Course 44
What HERT for MCI is Not? (Cont’d)What HERT for MCI is Not? (Cont’d)
Not a Hospital Emergency Incident Command System Not a Hospital Emergency Incident Command System (HEICS) Course:(HEICS) Course: HERT stresses HEICS as a valuable tool for hospitalsHERT stresses HEICS as a valuable tool for hospitals Recognizes all Hospital Incident Management Systems (HIMS)Recognizes all Hospital Incident Management Systems (HIMS) HERT emphasizes a hospital IMS during emergency responseHERT emphasizes a hospital IMS during emergency response HERT integrates its HIMS into all aspects of the courseHERT integrates its HIMS into all aspects of the course
DHS/NTCDHS/NTC B461 CourseB461 Course 55
What HERT for MCI is Not? (Cont’d)What HERT for MCI is Not? (Cont’d)
Not a Weapons of Mass Destruction (WMD) Course:Not a Weapons of Mass Destruction (WMD) Course: HERT emphasizes the handling of patients contaminated with HERT emphasizes the handling of patients contaminated with
CBRNE agentsCBRNE agents Recognizes attendee’s prior training and skills concerning these Recognizes attendee’s prior training and skills concerning these
agentsagents Attendees should receive additional training on WMD Events Attendees should receive additional training on WMD Events
from ODPfrom ODP
DHS/NTCDHS/NTC B461 CourseB461 Course 66
What HERT for MCI is Not? (Cont’d)What HERT for MCI is Not? (Cont’d)
Not a National Incident Management System (NIMS) Not a National Incident Management System (NIMS) Course:Course: HERT emphasizes the use of an incident management system HERT emphasizes the use of an incident management system
to comply with the NIMSto comply with the NIMS Recognizes attendee’s prior training in the NIMSRecognizes attendee’s prior training in the NIMS Has incorporated NIMS where it applies throughout the courseHas incorporated NIMS where it applies throughout the course Participants wanting additional training should enroll in FEMA’s Participants wanting additional training should enroll in FEMA’s
Online Courses in the NIMS:Online Courses in the NIMS:• IS 700 NIMS, An IntroductionIS 700 NIMS, An Introduction
• IS 800 NRP, An IntroductionIS 800 NRP, An Introduction
Unit OneUnit One
Course Introduction: Origin of the Course Introduction: Origin of the Incident Command System (ICS)Incident Command System (ICS)
DHS/NTCDHS/NTC B461 CourseB461 Course 88
ObjectivesObjectives
Review ICS as an incident management toolReview ICS as an incident management tool List uses of ICS in emergency managementList uses of ICS in emergency management Describe the history of ICSDescribe the history of ICS Discuss the evolution of HEICSDiscuss the evolution of HEICS Define basic HEICS structureDefine basic HEICS structure Review ICS organizational chartReview ICS organizational chart
DHS/NTCDHS/NTC B461 CourseB461 Course 99
Objectives (cont'd)Objectives (cont'd)
Develop an initial organizational structureDevelop an initial organizational structure List minimum staffing requirementsList minimum staffing requirements Prepare an incident briefingPrepare an incident briefing Participate in a planning meetingParticipate in a planning meeting Develop incident objectives and an Incident Action Plan Develop incident objectives and an Incident Action Plan
(IAP)(IAP) Identify appropriate uses of resourcesIdentify appropriate uses of resources
DHS/NTCDHS/NTC B461 CourseB461 Course 1010
What is ICS?What is ICS?
The model incident management tool for:The model incident management tool for: Command, control, and coordination of an emergency Command, control, and coordination of an emergency
responseresponse Providing a means to coordinate efforts of individual Providing a means to coordinate efforts of individual
agenciesagencies Allowing agencies to work toward a common goal for Allowing agencies to work toward a common goal for
stabilizing an incidentstabilizing an incident Ensuring the protection of life, property, and the Ensuring the protection of life, property, and the
environmentenvironment
DHS/NTCDHS/NTC B461 CourseB461 Course 1111
When is ICS Used?When is ICS Used?
Hazardous materials incidentsHazardous materials incidents Response to natural disastersResponse to natural disasters Fire and riot controlFire and riot control Incidents involving multiple casualties:Incidents involving multiple casualties:
Weapons of Mass DestructionWeapons of Mass Destruction Mass Casualty EventsMass Casualty Events
Wide-area search and rescue missionsWide-area search and rescue missions
DHS/NTCDHS/NTC B461 CourseB461 Course 1212
History of ICSHistory of ICS Developed in the 1970s in response to major wild Developed in the 1970s in response to major wild
land fires in Southern Californialand fires in Southern California Allowed for collaboration to form the:Allowed for collaboration to form the:
Firefighting Resources of Southern California Organized Firefighting Resources of Southern California Organized for Potential Emergencies, or FIRESCOPEfor Potential Emergencies, or FIRESCOPE
DHS/NTCDHS/NTC B461 CourseB461 Course 1313
History of ICS (cont'd)History of ICS (cont'd)
FIRESCOPE identified several recurring problems FIRESCOPE identified several recurring problems involving multi-agency responses, such as:involving multi-agency responses, such as: Nonstandard terminologyNonstandard terminology Lack of flexibility to expand or contract resources as Lack of flexibility to expand or contract resources as
requiredrequired Nonstandard and nonintegrated communicationsNonstandard and nonintegrated communications Lack of consolidated action plansLack of consolidated action plans Lack of designated facilitiesLack of designated facilities
DHS/NTCDHS/NTC B461 CourseB461 Course 1414
History of ICS (cont'd)History of ICS (cont'd)
Efforts to address these difficulties resulted in the Efforts to address these difficulties resulted in the development of an ICS modeldevelopment of an ICS model
Success of ICS has resulted directly from applying:Success of ICS has resulted directly from applying: A command organizational structureA command organizational structure Key standardized management principlesKey standardized management principles
DHS/NTCDHS/NTC B461 CourseB461 Course 1515
NIIMS versus NIMSNIIMS versus NIMS
NIIMS (existing):NIIMS (existing):
1.1. Incident Command System (ICS)Incident Command System (ICS)
2.2. TrainingTraining
3.3. Qualifications & CertificationQualifications & Certification
4.4. Publications ManagementPublications Management
5.5. Supporting TechnologySupporting Technology
NIMS (new):NIMS (new):
1.1. Command & Incident Command & Incident ManagementManagement
2.2. PreparednessPreparedness
3.3. Resource ManagementResource Management
4.4. Communications Information & Communications Information & Intelligence ManagementIntelligence Management
5.5. Science & Technology Science & Technology ManagementManagement
DHS/NTCDHS/NTC B461 CourseB461 Course 1616
Hospital Emergency Incident Hospital Emergency Incident Command System (HEICS)Command System (HEICS)
Modeled after FIRESCOPEModeled after FIRESCOPE Early work by the Northern California Hospital CouncilEarly work by the Northern California Hospital Council California authorized a grant to Orange Country EMS California authorized a grant to Orange Country EMS
for HEICS Project 91/92for HEICS Project 91/92 Major rewrite of HEICS documents:Major rewrite of HEICS documents:
Now provide the current HEICS PlanNow provide the current HEICS Plan
HEICS considered a model for hospital incident HEICS considered a model for hospital incident management systemmanagement system
DHS/NTCDHS/NTC B461 CourseB461 Course 1717
HEICS AttributesHEICS Attributes
HEICS attributes:HEICS attributes: Command, control, coordination, and intelligenceCommand, control, coordination, and intelligence
Functional incident management systemFunctional incident management system A dependable chain-of-commandA dependable chain-of-command Improved communications through common languageImproved communications through common language Flexibility in section (component) activationFlexibility in section (component) activation Prioritization of dutiesPrioritization of duties Adaptable to HazMat, WMD, and MCIAdaptable to HazMat, WMD, and MCI
DHS/NTCDHS/NTC B461 CourseB461 Course 1818
HEICS Attributes (cont'd)HEICS Attributes (cont'd)
Organized documentation for improved financial recoveryOrganized documentation for improved financial recovery Facilitates effective mutual aid with:Facilitates effective mutual aid with:
Other hospitals, andOther hospitals, and AgenciesAgencies
DHS/NTCDHS/NTC B461 CourseB461 Course 1919
Basic HEICS StructureBasic HEICS Structure
Basic units of structure:Basic units of structure: Incident CommanderIncident Commander Section ChiefsSection Chiefs DirectorsDirectors Unit LeadersUnit Leaders OfficersOfficers
DHS/NTCDHS/NTC B461 CourseB461 Course 2020
ICS Organizational ChartICS Organizational Chart
Represents lines of authority and communicationsRepresents lines of authority and communications Command element (IC and staff)Command element (IC and staff) Four functional sections:Four functional sections:
Planning Planning OperationsOperations Logistics, and Logistics, and Finance/AdministrationFinance/Administration
DHS/NTCDHS/NTC B461 CourseB461 Course 2121
ICS OrganizationICS Organization
IncidentIncidentCommandCommand
Finance/Finance/AdministrationAdministration
SectionSection
LogisticsLogisticsSectionSection
OperationsOperationsSectionSection
PlanningPlanningSectionSection
DHS/NTCDHS/NTC B461 CourseB461 Course 2222
Incident CommanderIncident Commander Incident Commander (IC):Incident Commander (IC):
Defines the mission and ensures its completionDefines the mission and ensures its completion Has overall control of incident or emergency Has overall control of incident or emergency
responseresponse Can appoint a deputy commanderCan appoint a deputy commander
DHS/NTCDHS/NTC B461 CourseB461 Course 2323
Command StaffCommand Staff
Safety OfficerSafety OfficerSafety OfficerSafety Officer
Liaison OfficerLiaison OfficerLiaison OfficerLiaison Officer
Public Information OfficerPublic Information OfficerPublic Information OfficerPublic Information Officer
IncidentIncidentCommandCommand
IncidentIncidentCommandCommand
DHS/NTCDHS/NTC B461 CourseB461 Course 2424
Command Staff (cont'd)Command Staff (cont'd) Command Staff is:Command Staff is:
Public Information OfficerPublic Information Officer Liaison OfficerLiaison Officer Safety OfficerSafety Officer Officers can also have AssistantsOfficers can also have Assistants
DHS/NTCDHS/NTC B461 CourseB461 Course 2525
General StaffGeneral Staff
IncidentIncidentCommandCommand
Finance/Finance/AdministrationAdministration
SectionSection
LogisticsLogisticsSectionSection
OperationsOperationsSectionSection
PlanningPlanningSectionSection
DHS/NTCDHS/NTC B461 CourseB461 Course 2626
Planning SectionPlanning Section Planning Section:Planning Section:
Determines and provides for the continuance of each Determines and provides for the continuance of each response objectiveresponse objective
Prompts and drives all Officers to develop:Prompts and drives all Officers to develop: Short-range action planningShort-range action planning Long-range action planningLong-range action planning
Responsible for preparing the IAPResponsible for preparing the IAP
DHS/NTCDHS/NTC B461 CourseB461 Course 2727
Planning Section (cont'd)Planning Section (cont'd)
Planning SectionPlanning Section
Demobilization Unit
Demobilization Unit
Documentation Unit
Documentation Unit
Situation Unit
Situation Unit
Resource Unit
Resource Unit
DHS/NTCDHS/NTC B461 CourseB461 Course 2828
Operations SectionOperations Section
Operations Section:Operations Section: Carries out the objectives to the best of the staff’s abilityCarries out the objectives to the best of the staff’s ability Oversees and directs all response operationsOversees and directs all response operations Determines needs and requests additional resourcesDetermines needs and requests additional resources
DHS/NTCDHS/NTC B461 CourseB461 Course 2929
Operations Section (cont'd)Operations Section (cont'd)
StagingArea(s)
MedicalBranch
Rescue
BranchMulti-Casualty
BranchHazMat Group
Operations Section
DHS/NTCDHS/NTC B461 CourseB461 Course 3030
Logistics SectionLogistics Section Logistics Section:Logistics Section:
Provides a hospitable environment and materials for the Provides a hospitable environment and materials for the overall objectivesoverall objectives
Ensures service and support for respondersEnsures service and support for responders
DHS/NTCDHS/NTC B461 CourseB461 Course 3131
Logistics Section (cont'd)Logistics Section (cont'd)
Logistics Section
Service Branch Support Branch
Communications Unit
Food Unit
Medical Unit
Supply Unit
Ground Support Unit
Facilities Unit
DHS/NTCDHS/NTC B461 CourseB461 Course 3232
Finance/Administration SectionFinance/Administration Section
Finance/Administration Section:Finance/Administration Section: Provides funding for present objectivesProvides funding for present objectives Stresses facility-wide documentation to Stresses facility-wide documentation to
maximize:maximize: Financial recovery, andFinancial recovery, and Reduction of future liabilityReduction of future liability
DHS/NTCDHS/NTC B461 CourseB461 Course 3333
Finance/Administration Section Finance/Administration Section (cont'd)(cont'd)
Finance/Admin Section
Cost Unit
Compensation/Claims Unit
Procurement Unit
Time Unit
DHS/NTCDHS/NTC B461 CourseB461 Course 3434
Future of the ICSFuture of the ICS Continues to expand throughout U.S.:Continues to expand throughout U.S.:
Law enforcementLaw enforcement Government agenciesGovernment agencies Hospitals and HCFHospitals and HCF
Will be revisited to ensure:Will be revisited to ensure: It remains relevant to response agencies, and It remains relevant to response agencies, and Current with standardized ICS modelsCurrent with standardized ICS models
Must be adaptable to include an ICS/UC structure for Must be adaptable to include an ICS/UC structure for HMI, MCI, and WMD eventsHMI, MCI, and WMD events
Should incorporate NIMS as adopted on March 1, 2004Should incorporate NIMS as adopted on March 1, 2004
Unit TwoUnit TwoHospital Incident Management Hospital Incident Management
System (HIMS)System (HIMS)
DHS/NTCDHS/NTC B461 CourseB461 Course 3636
ObjectivesObjectives
Describe Hospital Incident Management System for:Describe Hospital Incident Management System for: Planned & unplanned eventsPlanned & unplanned events Mass casualty incidentsMass casualty incidents HazMat incidentsHazMat incidents CBRNE eventsCBRNE events
Describe transfer of commandDescribe transfer of command
DHS/NTCDHS/NTC B461 CourseB461 Course 3737
HIMS – Operations Section MembersHIMS – Operations Section Members
HIMS Operations Section could consist of:HIMS Operations Section could consist of: Operations Section ChiefOperations Section Chief Group/Division SupervisorsGroup/Division Supervisors
• CBRNE or HazMat GroupCBRNE or HazMat Group• SHED or Cafeteria Division, etc.SHED or Cafeteria Division, etc.
Team MembersTeam Members
Triage and Treatment Unit LeadersTriage and Treatment Unit Leaders• Triage and Treatment Team MembersTriage and Treatment Team Members
Hospital Emergency Response Unit (HERU)Hospital Emergency Response Unit (HERU)• Team MembersTeam Members
DHS/NTCDHS/NTC B461 CourseB461 Course 3838
HIMS – Operations Section HIMS – Operations Section OrganizationOrganization
SHED Division Cafeteria Division CBRNE Group
Operations Section
DHS/NTCDHS/NTC B461 CourseB461 Course 3939
Medical Care Group/DivisionMedical Care Group/DivisionMembersMembers
Medical Care Group/Division could consist of:Medical Care Group/Division could consist of: Medical Group/Division Supervisor:Medical Group/Division Supervisor:
• Triage Unit LeaderTriage Unit Leader Triage personnelTriage personnel
• Treatment Unit LeaderTreatment Unit Leader Treatment Dispatcher ManagerTreatment Dispatcher Manager Treatment ManagersTreatment Managers
• Immediate, Delayed and MinorImmediate, Delayed and Minor Patient Transport Group SupervisorPatient Transport Group Supervisor
• Medical Communications CoordinatorMedical Communications Coordinator• Air/Ground Ambulance CoordinatorAir/Ground Ambulance Coordinator
DHS/NTCDHS/NTC B461 CourseB461 Course 4040
Medical Care Group/DivisionMedical Care Group/DivisionMembers (Cont’d)Members (Cont’d)
Command from the top downCommand from the top down Staff from the bottom up:Staff from the bottom up:
Start with Team or Unit when possibleStart with Team or Unit when possible Staff up as span of control is exceededStaff up as span of control is exceeded
Maintain unity of commandMaintain unity of command Divisions are geographical:Divisions are geographical:
North/South; East/West; 1North/South; East/West; 1stst floor/2 floor/2ndnd floor floor
DHS/NTCDHS/NTC B461 CourseB461 Course 4141
Medical Care Group/DivisionMedical Care Group/DivisionMembers (Cont’d)Members (Cont’d)
Groups are functional:Groups are functional: Security, medical careSecurity, medical care CBRNE or HazMatCBRNE or HazMat
Groups can have Units:Groups can have Units: TriageTriage TreatmentTreatment Hospital Emergency Response Unit (HERU)Hospital Emergency Response Unit (HERU)
Units may have TeamsUnits may have Teams DecontaminationDecontamination
DHS/NTCDHS/NTC B461 CourseB461 Course 4242
Medical Care Group/Division Medical Care Group/Division Organization Organization
Medical SupplyCoordinator
Triage Personnel
Triage UnitLeader
Treatment DispatchManager
Immediate TreatmentManager
Delayed TreatmentManager
Minor TreatmentManager
Treatment UnitLeader
Medical Care Group/Division Supervisor
Morgue Manager
DHS/NTCDHS/NTC B461 CourseB461 Course 4343
HazMat/CBRNE Unit MembersHazMat/CBRNE Unit Members
HazMat/CBRNE Unit LeaderHazMat/CBRNE Unit Leader Entry Team LeaderEntry Team Leader Hospital Site Access Control LeaderHospital Site Access Control Leader Safe Refuge Area ManagerSafe Refuge Area Manager Decontamination Team LeaderDecontamination Team Leader Technical SpecialistTechnical Specialist Assistant Hospital Safety Officer – HazMatAssistant Hospital Safety Officer – HazMat
DHS/NTCDHS/NTC B461 CourseB461 Course 4444
HazMat/CBRNE Unit OrganizationHazMat/CBRNE Unit Organization
Entry
Hospital Access Control
Safe Refuge Area
Decontamination
Technical Specialists
HazMat/CBRNEUnit
DHS/NTCDHS/NTC B461 CourseB461 Course 4545
Hospital Emergency Response Hospital Emergency Response Unit* (HERU)Unit* (HERU)
HERU LeaderHERU Leader Hospital Emergency Response Team (HERT) LeaderHospital Emergency Response Team (HERT) Leader
Initial Assessment & TriageInitial Assessment & Triage Immediate TreatmentImmediate Treatment Delayed TreatmentDelayed Treatment Minor TreatmentMinor Treatment
*Unit can be replaced by a Team*Unit can be replaced by a Team
DHS/NTCDHS/NTC B461 CourseB461 Course 4646
HERU/HERT OrganizationHERU/HERT Organization
InitialAssessment/
Triage
ImmediateTreatment
Delayed Treatment
Minor Treatment
HERU/HERT Leader
DHS/NTCDHS/NTC B461 CourseB461 Course 4747
Decon Team MembersDecon Team Members
Decontamination Team LeaderDecontamination Team Leader Initial ContactInitial Contact Decon Triage*Decon Triage* Decon Site Access ControlDecon Site Access Control Decon Set-up and SupportDecon Set-up and Support
*Patient/victim is continually triaged*Patient/victim is continually triaged
DHS/NTCDHS/NTC B461 CourseB461 Course 4848
Decon Team OrganizationDecon Team Organization
Initial Contact Decon Triage Decon Site
Access Control
Decon Set Up/
Support
Decon Team Leader
DHS/NTCDHS/NTC B461 CourseB461 Course 4949
Scenario ObjectivesScenario Objectives
Identify initial incident objectivesIdentify initial incident objectives Incident prioritiesIncident priorities
Life Safety (staff and patients)Life Safety (staff and patients) Incident StabilityIncident Stability Property preservationProperty preservation
Activate ICSActivate ICS Fill positions as appropriate for the eventFill positions as appropriate for the event Key points:Key points:
Span of control (3 – 7)Span of control (3 – 7) Unity of commandUnity of command
DHS/NTCDHS/NTC B461 CourseB461 Course 5050
Scenario – Planned EventScenario – Planned Event
Noble Hospital is Noble Hospital is planning their annual planning their annual fundraiser:fundraiser: A two day Fish Fry Festival. A two day Fish Fry Festival. Saturday and Sunday, Saturday and Sunday,
Noon to 10 pmNoon to 10 pm
Menu:Menu:
Fried catfish, Cole Slaw, Fried catfish, Cole Slaw, Beans, Hush Puppies, Beans, Hush Puppies, CornbreadCornbreadIce Cream ConesIce Cream ConesBeerBeerSodaSoda
Entertainment:Entertainment:8 bands, 2 magician shows8 bands, 2 magician shows
Vendors:Vendors:20 Arts & Craft booths20 Arts & Craft boothsChildren’s Play areaChildren’s Play area
DHS/NTCDHS/NTC B461 CourseB461 Course 5151
Section ConsiderationsSection Considerations
Initial Incident ObjectivesInitial Incident Objectives What are the main functions for:What are the main functions for:
(Operations, Logistics, Planning and Finance/Admin)?(Operations, Logistics, Planning and Finance/Admin)?
Should the functions be divided?Should the functions be divided? If so, how?If so, how?
DHS/NTCDHS/NTC B461 CourseB461 Course 5252
Scenario – Unplanned EventScenario – Unplanned Event
A complete, community-wide power outage has occurred A complete, community-wide power outage has occurred approximately 20 minutes ago. United Electric Company has approximately 20 minutes ago. United Electric Company has just informed you that there is a 50 mile blackout, cause is just informed you that there is a 50 mile blackout, cause is unknown. Outage expected to last 5-7 days.unknown. Outage expected to last 5-7 days.
Emergency generators functioning with enough fuel for 1.5 Emergency generators functioning with enough fuel for 1.5 days at current emergency load. Emergency equipment is days at current emergency load. Emergency equipment is working only. working only.
The following departments are not on emergency power:The following departments are not on emergency power:Business officeBusiness office RegistrationRegistrationInfection ControlInfection Control AdministrationAdministrationPhysical TherapyPhysical Therapy All offices in hospitalAll offices in hospitalPneumatic tube systemPneumatic tube system
DHS/NTCDHS/NTC B461 CourseB461 Course 5353
Scenario – Unplanned Event (Cont’d)Scenario – Unplanned Event (Cont’d)
Departments on emergency power for critical functions:Departments on emergency power for critical functions:
Emergency DeptEmergency Dept ICU/CCUICU/CCU Medical gasesMedical gases
LabLab XRayXRay NurseryNursery
SurgerySurgery RecoveryRecovery Nursing UnitsNursing Units
PharmacyPharmacy SwitchboardSwitchboard Summer weather - 90Summer weather - 90°/58°°/58° Population 250,000Population 250,000 Two hospitals, multiple clinics in areaTwo hospitals, multiple clinics in area
Noble Hospital – 250 beds/85% full; total hospital staff 1800Noble Hospital – 250 beds/85% full; total hospital staff 1800
DHS/NTCDHS/NTC B461 CourseB461 Course 5454
Section ConsiderationsSection Considerations
Initial Incident ObjectivesInitial Incident Objectives What are the main functions for:What are the main functions for:
(Operations, Logistics, Planning and Finance/Admin)?(Operations, Logistics, Planning and Finance/Admin)?
Should the functions be divided?Should the functions be divided? If so, how?If so, how?
DHS/NTCDHS/NTC B461 CourseB461 Course 5555
Scenario -- Mass Casualty EventScenario -- Mass Casualty Event
There was a stadium collapse at the fairgrounds.There was a stadium collapse at the fairgrounds.Capacity of the stadium is 5000 people. Report fromCapacity of the stadium is 5000 people. Report fromEMS indicate over 300 people injured with many fleeingEMS indicate over 300 people injured with many fleeingthe scene in private vehicles. The county Mass Casualtythe scene in private vehicles. The county Mass CasualtyPlan has been activatedPlan has been activated. .
Summer weather - 90Summer weather - 90°/58°°/58° Population 250,000Population 250,000 Two hospitals, multiple clinics in areaTwo hospitals, multiple clinics in area Noble Hospital – 250 beds/85% full; total hospital staff 1800Noble Hospital – 250 beds/85% full; total hospital staff 1800 ED has 20 beds – currently has 16 patientsED has 20 beds – currently has 16 patients
DHS/NTCDHS/NTC B461 CourseB461 Course 5656
Section ConsiderationsSection Considerations
Initial Incident ObjectivesInitial Incident Objectives What are the main functions for:What are the main functions for:
(Operations, Logistics, Planning and Finance/Admin)?(Operations, Logistics, Planning and Finance/Admin)?
Should the functions be divided?Should the functions be divided? If so, how?If so, how?
DHS/NTCDHS/NTC B461 CourseB461 Course 5757
Scenario – Haz Mat IncidentScenario – Haz Mat Incident
Continuation of stadium collapseContinuation of stadium collapse
There were 20 people that were contaminatedThere were 20 people that were contaminatedWith Organophosphate when the holding tank With Organophosphate when the holding tank was punctured from a piece of the stadiumwas punctured from a piece of the stadium
Some have left the scene en-route to the Some have left the scene en-route to the hospital. EMS will be transporting 6 after hospital. EMS will be transporting 6 after gross decontamination (clothing removed gross decontamination (clothing removed and field shower) and field shower)
DHS/NTCDHS/NTC B461 CourseB461 Course 5858
Section ConsiderationsSection Considerations
Initial Incident ObjectivesInitial Incident Objectives What are the main functions for:What are the main functions for:
(Operations, Logistics, Planning and Finance/Admin)?(Operations, Logistics, Planning and Finance/Admin)?
Should the functions be divided?Should the functions be divided? If so, how?If so, how?
DHS/NTCDHS/NTC B461 CourseB461 Course 5959
Transfer of CommandTransfer of Command
Transfer command to an equal or more qualified Transfer command to an equal or more qualified person person
Transfer of command requires:Transfer of command requires: Briefing of incident face to faceBriefing of incident face to face Notification of staff that transfer has occurred AND Notification of staff that transfer has occurred AND
the name of the new personthe name of the new person
DHS/NTCDHS/NTC B461 CourseB461 Course 6060
Transfer of Command (Cont’d)Transfer of Command (Cont’d)
Command transfers to a Command transfers to a more qualifiedmore qualified IC when IC when necessarynecessary
The new IC will The new IC will always always receive a transfer-of-receive a transfer-of-command briefingcommand briefing
Hospitals and healthcare facilities must identify Hospitals and healthcare facilities must identify and train deputy ICsand train deputy ICs
DHS/NTCDHS/NTC B461 CourseB461 Course 6161
SummarySummary
ICS can be used for planned AND unplanned ICS can be used for planned AND unplanned events involving the hospitalevents involving the hospital
Make the response fit the event – only fill the Make the response fit the event – only fill the positions that are neededpositions that are needed
Maintain span of control (3 – 7 people)Maintain span of control (3 – 7 people) Use branches and divisions as neededUse branches and divisions as needed Expand and contract assignments as neededExpand and contract assignments as needed
Transfer of Command must be done consistently Transfer of Command must be done consistently and completely and completely
DHS/NTCDHS/NTC B461 CourseB461 Course 6262
Summary (Cont’d)Summary (Cont’d)
Incident priorities:Incident priorities: Life safety of care providersLife safety of care providers Patient stability and treatmentPatient stability and treatment Property conservationProperty conservation Protect the environmentProtect the environment
Unit ThreeUnit Three
Topic 3-1: Chemical and Biological Topic 3-1: Chemical and Biological Agents in TerrorismAgents in Terrorism
DHS/NTCDHS/NTC B461 CourseB461 Course 6464
ObjectivesObjectives
Overview of potential biological agents used in Overview of potential biological agents used in terrorismterrorism
Overview of potential chemical agents used in Overview of potential chemical agents used in terrorismterrorism
Overview of common syndromesOverview of common syndromes Define clinical management procedures for Define clinical management procedures for
chemical/biological agentschemical/biological agents Define guidelines for response plansDefine guidelines for response plans
DHS/NTCDHS/NTC B461 CourseB461 Course 6565
Routes of ExposureRoutes of Exposurefor Chemical and Biological Agentsfor Chemical and Biological Agents
InhalationInhalation Inhalation of droplets, aerosols or vaporsInhalation of droplets, aerosols or vapors
AbsorptionAbsorption Intact skin, cuts or abrasionsIntact skin, cuts or abrasions
Mucous membranesMucous membranes
InjectionInjection Intentional or unintentionalIntentional or unintentional
IngestionIngestion Specific agent ingestionSpecific agent ingestion
Contaminated food or waterContaminated food or water
DHS/NTCDHS/NTC B461 CourseB461 Course 6666
Bioterrorism (CDC Definition)Bioterrorism (CDC Definition)
“ “Bioterrorism is the intentional or threatened use of Bioterrorism is the intentional or threatened use of viruses, bacteria, fungi, toxins from living organisms viruses, bacteria, fungi, toxins from living organisms or other chemicals to produce death or disease in or other chemicals to produce death or disease in humans, animals or plants.”humans, animals or plants.”
DHS/NTCDHS/NTC B461 CourseB461 Course 6767
Potential Bioterrorism AgentsPotential Bioterrorism Agents
Bacterial AgentsBacterial Agents AnthraxAnthrax BrucellosisBrucellosis CholeraCholera Pneumonic plaguePneumonic plague TularemiaTularemia Q FeverQ Fever
VirusesViruses SmallpoxSmallpox Venezuelan Equine EncephalitisVenezuelan Equine Encephalitis Viral Hemorrhagic FeverViral Hemorrhagic Fever
Biological ToxinsBiological Toxins BotulinumBotulinum Staph Entero-BStaph Entero-B RicinRicin T-2 MycotoxinsT-2 Mycotoxins
DHS/NTCDHS/NTC B461 CourseB461 Course 6868
Mandatory Reporting GuidelinesMandatory Reporting Guidelines
> Know your state and local guidelines> Know your state and local guidelines
> Include them in your plans> Include them in your plans
ANDAND
> Train your staff> Train your staff
DHS/NTCDHS/NTC B461 CourseB461 Course 6969
CDC Category Definitions of CDC Category Definitions of Diseases/AgentsDiseases/Agents
Category ACategory A - Highest priority - Highest priority Can be easily disseminated or transmitted from person to Can be easily disseminated or transmitted from person to
personperson Results in high mortality rates and have the potential for Results in high mortality rates and have the potential for
major public health impactmajor public health impact Might cause public panic and social disruption Might cause public panic and social disruption Require special action for public health preparednessRequire special action for public health preparedness
Category A – AgentsCategory A – Agents AnthraxAnthrax ( (Bacillus anthracisBacillus anthracis); ); BotulismBotulism ( (Clostridium Clostridium
botulinumbotulinum toxin); toxin); PlaguePlague ( (Yersinia pestisYersinia pestis); ); SmallpoxSmallpox (variola major); (variola major); TularemiaTularemia ( (Francisella tularensisFrancisella tularensis); and ); and Viral hemorrhagic feversViral hemorrhagic fevers (filoviruses [e.g., Ebola, Marburg] (filoviruses [e.g., Ebola, Marburg] and arenaviruses [e.g., Lassa, Machupo])and arenaviruses [e.g., Lassa, Machupo])
DHS/NTCDHS/NTC B461 CourseB461 Course 7070
CDC Category Definitions of CDC Category Definitions of Diseases/Agents (cont)Diseases/Agents (cont)
Category B Category B – Second highest priority– Second highest priority Moderately easy to disseminateModerately easy to disseminate Result in moderate morbidity rates and low mortality ratesResult in moderate morbidity rates and low mortality rates Require special enhancements of CDC’s diagnostic Require special enhancements of CDC’s diagnostic
capacity and enhanced disease surveillancecapacity and enhanced disease surveillance
Category B – AgentsCategory B – Agents BrucellosisBrucellosis ( (BrucellaBrucella species); Epsilon toxin of species); Epsilon toxin of Clostridium Clostridium
perfringens; perfringens; Food safety threatsFood safety threats (e.g., (e.g., SalmonellaSalmonella species, species, Escherichia coliEscherichia coli O157:H7, O157:H7, ShigellaShigella); Glanders ); Glanders ((Burkholderia malleiBurkholderia mallei); Melioidosis (); Melioidosis (Burkholderia Burkholderia pseudomalleipseudomallei); Psittacosis (); Psittacosis (Chlamydia psittaciChlamydia psittaci); ); Q feverQ fever ((Coxiella burnetiiCoxiella burnetii))
DHS/NTCDHS/NTC B461 CourseB461 Course 7171
CDC Category Definitions of CDC Category Definitions of Diseases/Agents (cont)Diseases/Agents (cont)
Category B – Agents (Cont)Category B – Agents (Cont) Ricin toxinRicin toxin from from Ricinus communisRicinus communis (castor beans); (castor beans);
Staphylococcal enterotoxin BStaphylococcal enterotoxin B»»Typhus fever (Typhus fever (Rickettsia Rickettsia prowazekiiprowazekii); Viral encephalitis (alphaviruses [e.g., ); Viral encephalitis (alphaviruses [e.g., Venezuelan equine encephalitis, eastern equine Venezuelan equine encephalitis, eastern equine encephalitis, western equine encephalitis]); and Water encephalitis, western equine encephalitis]); and Water safety threats (e.g., safety threats (e.g., Vibrio choleraeVibrio cholerae, , Cryptosporidium Cryptosporidium parvumparvum))
DHS/NTCDHS/NTC B461 CourseB461 Course 7272
CDC Category Definitions of CDC Category Definitions of Diseases/Agents (cont)Diseases/Agents (cont)
Category CCategory C – Third highest priority – Third highest priority Includes emerging pathogens that could be engineered for Includes emerging pathogens that could be engineered for
mass dissemination in the future because of mass dissemination in the future because of
> availability> availability
> ease of production and dissemination> ease of production and dissemination
> potential for high morbidity/mortality > potential for high morbidity/mortality
rates and major health impactrates and major health impact
Category C – AgentsCategory C – Agents Nipah virus and hantavirus Nipah virus and hantavirus
DHS/NTCDHS/NTC B461 CourseB461 Course 7373
Most Common Syndromes in Most Common Syndromes in Biological EventsBiological Events
Flu-like illnessesFlu-like illnesses Acute respiratory symptoms with feverAcute respiratory symptoms with fever Gastrointestinal symptoms/syndromesGastrointestinal symptoms/syndromes Skin lesions (small pox)Skin lesions (small pox) Acute neuromuscular syndromesAcute neuromuscular syndromes
Compliments of CDC/NIP/Barbara Rice
DHS/NTCDHS/NTC B461 CourseB461 Course 7474
Clues to Biological Potential EventsClues to Biological Potential Events
Increase in the number of patients with similar Increase in the number of patients with similar symptomssymptoms
Large number of deathsLarge number of deaths Cluster of an illness from single areaCluster of an illness from single area Infection that is not endemic to areaInfection that is not endemic to area Common infections in unusual seasonsCommon infections in unusual seasons Increase/large number of sick/dead animalsIncrease/large number of sick/dead animals Intelligence from law enforcementIntelligence from law enforcement Stated threatStated threat
DHS/NTCDHS/NTC B461 CourseB461 Course 7575
Priorities for ResponsePriorities for Response(All Hazards)(All Hazards)
Life safetyLife safety Staff Staff VictimsVictims
Incident stabilityIncident stability Property preservationProperty preservation Protection of the environmentProtection of the environment
DHS/NTCDHS/NTC B461 CourseB461 Course 7676
Response Considerations for Response Considerations for Biological EventBiological Event
Planning:Planning: Develop policies and procedures for:Develop policies and procedures for:
• recognition recognition
• notification notification
• isolation/quarantineisolation/quarantine
Pre-exposure:Pre-exposure: Active immunizationActive immunization ProphylaxisProphylaxis Intelligence informationIntelligence information
DHS/NTCDHS/NTC B461 CourseB461 Course 7777
Response Considerations for Response Considerations for Biological Event (Cont’d)Biological Event (Cont’d)
Incubation Period:Incubation Period: DiagnosisDiagnosis Active/passive immunizationActive/passive immunization Antimicrobial treatmentAntimicrobial treatment Public Health needs (isolation/quarantine)Public Health needs (isolation/quarantine)
Active Disease Period:Active Disease Period: DiagnosisDiagnosis Treatment (guided by diagnosis & symptoms)Treatment (guided by diagnosis & symptoms) Public Health needs (isolation/quarantine)Public Health needs (isolation/quarantine)
DHS/NTCDHS/NTC B461 CourseB461 Course 7878
Clinical Consideration for Clinical Consideration for Biological Event Biological Event
Basic supplies/address surge capacity:Basic supplies/address surge capacity: Beds/linensBeds/linens Waste managementWaste management Lab suppliesLab supplies Medical supplies:Medical supplies:
• IV solutions and suppliesIV solutions and supplies
• Antibiotics (if needed)Antibiotics (if needed)
• Other medicationsOther medications
DHS/NTCDHS/NTC B461 CourseB461 Course 7979
Clinical Consideration for Clinical Consideration for Biological Event (Cont’d)Biological Event (Cont’d)
Additional needs:Additional needs: Extended staffing plan (clinical/non-clinical)Extended staffing plan (clinical/non-clinical) Medical staffing planMedical staffing plan Mass casualty planMass casualty plan Mass fatality planMass fatality plan Media management plan (Joint Information Center)Media management plan (Joint Information Center)
• Mechanism to provide updates/info to staffMechanism to provide updates/info to staff
DHS/NTCDHS/NTC B461 CourseB461 Course 8080
Clinical Consideration for Clinical Consideration for Biological Event (Cont’d)Biological Event (Cont’d)
Additional needs:Additional needs: Infection Control Practitioner (from hospital)Infection Control Practitioner (from hospital) Public Health representativePublic Health representative Considering activating the hospital ICS/UCSConsidering activating the hospital ICS/UCS Family support areaFamily support area Pharmaceutical stockpilesPharmaceutical stockpiles
DHS/NTCDHS/NTC B461 CourseB461 Course 8181
Key PointsKey Points
Some exposures Some exposures maymay require decontamination but require decontamination but most do notmost do not
Large events may overwhelm your systemLarge events may overwhelm your system Assure that the right people are notified and included Assure that the right people are notified and included
in the responsein the response Implement Incident Command SystemImplement Incident Command System
DHS/NTCDHS/NTC B461 CourseB461 Course 8282
RemindersReminders
Determine alternate care sites in the Planning PhaseDetermine alternate care sites in the Planning Phase Work with community partners in the Planning PhaseWork with community partners in the Planning Phase
DHS/NTCDHS/NTC B461 CourseB461 Course 8383
Potential Chemical AgentsPotential Chemical Agents
Nerve AgentsNerve Agents Blister Agents (vesicants)Blister Agents (vesicants) Pulmonary AgentsPulmonary Agents Blood Agents (cyanides)Blood Agents (cyanides)
Toxic Industrial ChemicalsToxic Industrial Chemicals
Riot Control AgentsRiot Control Agents
View from World Trade Center. Compliment of CDC.
DHS/NTCDHS/NTC B461 CourseB461 Course 8484
Comparative Toxicity of AgentsComparative Toxicity of Agents
0
1000
2000
3000
4000
5000
6000
CL CG AC H GB VX
AGENT (L) (L)(L)(L)(L)(L)
Ct50(mg-min/m3)
DHS/NTCDHS/NTC B461 CourseB461 Course 8585
Nerve AgentsNerve Agents
Actions:Actions: Interferes with the action of the nervous systemInterferes with the action of the nervous system Similar to organophosphatesSimilar to organophosphates
Types:Types: Sarin (GB)Sarin (GB) Tabun (GA)Tabun (GA) Soman (GD)Soman (GD) GFGF VXVX
Tokyo, Japan Response to Sarin Attack.
DHS/NTCDHS/NTC B461 CourseB461 Course 8686
Blister AgentsBlister Agents
Actions:Actions: Cause cellular damage leading to cellular death (skin, Cause cellular damage leading to cellular death (skin,
mucous membranes, eyes, systemic effects)mucous membranes, eyes, systemic effects) Effects begin immediately, but blisters may be delayed Effects begin immediately, but blisters may be delayed
(mustard) (mustard) Types:Types:
Mustard aka “mustard gas” (H)Mustard aka “mustard gas” (H) Sulfur mustard (HD)Sulfur mustard (HD) Lewisite (L)Lewisite (L) Mustard and Lewisite (HL)Mustard and Lewisite (HL) Phosgene Oxime (CX):Phosgene Oxime (CX):
• Pulmonary agent with vesicant effectsPulmonary agent with vesicant effects
Iran Victim of Mustard Agent Attack, CDC
DHS/NTCDHS/NTC B461 CourseB461 Course 8787
Pulmonary AgentsPulmonary Agents
Actions:Actions: Damages the lining in the lung and cause fluid leakageDamages the lining in the lung and cause fluid leakage Delayed pulmonary edemaDelayed pulmonary edema
Types:Types: Phosgene (CG)Phosgene (CG) Chlorine (CL)Chlorine (CL) RicinRicin
Pulmonary edema. Compliments of CDC.
DHS/NTCDHS/NTC B461 CourseB461 Course 8888
Blood Agents: CyanidesBlood Agents: Cyanides
Actions:Actions: Blocks the use of oxygen in the cells of the bodyBlocks the use of oxygen in the cells of the body
• Causing asphyxiation in each cellCausing asphyxiation in each cell Least toxic of the “lethal” chemical agentsLeast toxic of the “lethal” chemical agents
Types:Types: AC and CKAC and CK
Toxic industrial chemicals (TIC):Toxic industrial chemicals (TIC): Chlorine, ammonia, arsenicChlorine, ammonia, arsenic Hydrocarbon (benzene)Hydrocarbon (benzene) Highly toxic, corrosive and irritating chemicalsHighly toxic, corrosive and irritating chemicals
Likely terrorist’s targets of opportunityLikely terrorist’s targets of opportunity
DHS/NTCDHS/NTC B461 CourseB461 Course 8989
Riot AgentsRiot Agents
Actions:Actions: Causes irritation to eyes, mouth, throat, lungs and Causes irritation to eyes, mouth, throat, lungs and
skinskin Immediate symptoms are intense and cause people Immediate symptoms are intense and cause people
to try and stop the effectsto try and stop the effects Types:Types:
MaceMace Pepper SprayPepper Spray
DHS/NTCDHS/NTC B461 CourseB461 Course 9090
Clues To Potential Clues To Potential Chemical ExposureChemical Exposure
Shortness of breath/respiratory difficultyShortness of breath/respiratory difficulty Itchy/burning/watery eyesItchy/burning/watery eyes Runny noseRunny nose Skin irritationSkin irritation SLUDGESLUDGE Patients reporting odor just prior to symptomsPatients reporting odor just prior to symptoms
DHS/NTCDHS/NTC B461 CourseB461 Course 9191
Clues To Potential Clues To Potential Chemical Exposure (Cont)Chemical Exposure (Cont)
Increase number of patients with same symptomsIncrease number of patients with same symptoms Sick/dead animals and birdsSick/dead animals and birds Sick/affected first respondersSick/affected first responders Intelligence from lawIntelligence from law enforcementenforcement Stated threatStated threat
DHS/NTCDHS/NTC B461 CourseB461 Course 9292
Planning Considerations for Planning Considerations for Chemical AgentsChemical Agents
Planning PhasePlanning Phase Hazard assessmentHazard assessment Designate Triage and Decon areasDesignate Triage and Decon areas Develop Respiratory Protection ProgramDevelop Respiratory Protection Program Develop Decontamination ProgramDevelop Decontamination Program Implement Incident Command SystemImplement Incident Command System Purchase equipmentPurchase equipment Develop policies and proceduresDevelop policies and procedures Train staffTrain staff Practice and exercisePractice and exercise
DHS/NTCDHS/NTC B461 CourseB461 Course 9393
Response Plan Considerations Response Plan Considerations for Chemical Agentsfor Chemical Agents
RecognitionRecognition Prevent secondary contaminationPrevent secondary contamination
Escort patient immediately outside/to decon areaEscort patient immediately outside/to decon area Initiate hospital HazMat response:Initiate hospital HazMat response:
Notify appropriate staffNotify appropriate staff Don appropriate CPC&EDon appropriate CPC&E
DHS/NTCDHS/NTC B461 CourseB461 Course 9494
Response Plan Considerations for Response Plan Considerations for Chemical Agents (Cont)Chemical Agents (Cont)
Determine need for decontaminationDetermine need for decontamination Decontaminate patientsDecontaminate patients
Provide appropriate medical careProvide appropriate medical care Decontaminate staffDecontaminate staff Secure areaSecure area Decontaminate equipment, as appropriateDecontaminate equipment, as appropriate
DHS/NTCDHS/NTC B461 CourseB461 Course 9595
Antidotes Are Available forAntidotes Are Available forSome Chemical AgentsSome Chemical Agents
Nerve agents/organophosphatesNerve agents/organophosphates Atropine – blocks the effects of the chemical that Atropine – blocks the effects of the chemical that
causes over stimulationcauses over stimulation 2PAMCl – neutralizes the nerve agent actions2PAMCl – neutralizes the nerve agent actions CANA – Convulsive Antidote, Nerve AgentCANA – Convulsive Antidote, Nerve Agent
• Diazepam, when requiredDiazepam, when required CyanideCyanide
Cyanide Kit containsCyanide Kit contains• Amyl nitrate (inhalant)Amyl nitrate (inhalant)• Sodium nitrite (injectable)Sodium nitrite (injectable)• Sodium thiosulfate (injectable)Sodium thiosulfate (injectable)
DHS/NTCDHS/NTC B461 CourseB461 Course 9696
Hospital Partners for Biological & Hospital Partners for Biological & Chemical Response PlansChemical Response Plans
HazMat Team Patient
Administration
Infection Control
Laboratory
Housekeeping
ED Staff
Clinical Services
Risk & Materials Management
Legal
Hospital Emergency Management
PIO
Plant Operations
DHS/NTCDHS/NTC B461 CourseB461 Course 9797
Community Partners for Biological & Community Partners for Biological & Chemical Response PlansChemical Response Plans
Hospital
State Health Dept
Law Enforcement
State LabLocal Haz Mat Team
LEPC Local Health Dept
Elected Officials
CDC EMS
FBI
MediaCoroner
County Emergency Management
DHS/NTCDHS/NTC B461 CourseB461 Course 9898
Key PointsKey Points
Some exposures Some exposures maymay require decontamination but require decontamination but you must determine if patient was actually you must determine if patient was actually contaminatedcontaminated
Large events may overwhelm your system quickly Large events may overwhelm your system quickly and without noticeand without notice
Notified and included the right people in the responseNotified and included the right people in the response
DHS/NTCDHS/NTC B461 CourseB461 Course 9999
SummarySummary
Routes of exposure for chemical and biological Routes of exposure for chemical and biological agentsagents
Overview of some potential biological and chemical Overview of some potential biological and chemical agents used in terrorismagents used in terrorism
Overview of common syndromesOverview of common syndromes Guidelines for response plansGuidelines for response plans