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Dedicated to my beautiful and loving wife, Sue, and daughter, Jennifer.

—D. B.

To Kristi, Abby, Kate & Emerson. Thank you for all your love, support and patience.

—E. C.

I would like to thank my family for the idiosyncrasies I demonstrated as I went through the throes of contributing to this text. After several decades of being the one who responded to other people’s emergencies, I am hoping this text will one day serve me well should one of my family members need the services provided by one of the readers. The eighth anniversary of the attacks of September 11, 2001, has just passed as I pen this, and this text is dedicated to reminding us all of the need to never forget what happened that day.

—J. G.

ix

Preface

This hospital emergency response team (HERT) textbook was born out of nearly three decades of participating and observing in emergency medical response, planning, training and exercises, with both civilian and military medical entities. Day in and day out, personnel who have dedicated their lives to taking care of oth-ers perform admirably. In this author’s experience, units that operate at the peak of efficiency and effectiveness share the attributes of good training, on-the-job experience, and leadership. Disasters pose a challenge to these traits observed in high-performing teams. Rarely is training adequate, few personnel have disaster response experience, and unfortunately, expending limited hospital resources on disaster preparedness does not often lengthen any Chief Executive Officer’s tenure.

Having trained for response in the medical field, fire service, and tactical police operations, this author noted an interesting trend. My experience with SWAT training involved very little “pretending.” We were training as we planned on fighting. Fire department training varied, but a “burn to learn” approach was treated very seriously as poor performance here could lead to fire fighter injury or death. Medical training, conversely, involved a tremendous amount of pretend-ing: verbalizing what I would have done, and paper drills. When police and fire perform poorly, they get hurt, but when medical personnel perform poorly, their patient gets hurt.

The author was helping assess and train medical personnel on Okinawa when an event occurred that cemented his philosophy that the medical field must engage in simpler but more robust training. A hospital had scheduled a drill for their field and emergency department personnel. I went out in the field to observe the response to a traffic accident scenario, which had been set up near a sports field. The call was placed to dispatch and while waiting for the units to arrive I noticed a handful of Marines practicing hand to hand combat, as their next stop from here was the Middle East. Time after time, they repeated various moves, gaining that muscle memory that they hoped would keep them alive. I was brought back to the drill when I heard radio traffic which indicated that

x PREFACE

the medical personnel were questioning the need to respond to the drill. It took several additional phone calls to get any medical personnel to show up and train. Throughout the ordeal of getting the medical personnel to report for training, this handful of Marines continued going through their evolutions, apparently oblivi-ous to the lack of interest in training by the very medical personnel they would be counting on to save their lives should things go badly.

This book is about training hospital personnel in the same manner you want them to fight. Choosing your battlefield always gives you an advantage; however, disasters present us with an environment that is very unfamiliar to us, so we must also train outside the comfort of our facility walls. Disasters also tend to be non-discriminatory, they affect all of us the same, and therefore we need to realize that when disaster strikes, the entire community has a problem that is best solved by everyone working together to mitigate the event. Life safety should always be your first priority and by developing your HERT as outlined within this text, adopting a rigorous and regular training program, you will not just be giving lip service to disaster preparedness, you will be building a real capacity to change patient out-comes in the worst event of your career.

—Jan Glarum

1

1Command and Control

Chapter ObjeCtives

Review NIMS Implementation Activities for Hospitals and Health Care Systems•

Understand the mission of HICS IV•

Describe implementation issues, requirements, and timelines in establishing an internal •HICS IV program

IntroductionAny type of crisis or disaster, occurring anytime, can impact the operation ofhealthcarefacilitiesifthefacilityhasnottakentheopportunitytopreparebefore-hand.Anallhazardsapproachhelpshealthcarefacilitiesprepareforanytypeofevent. The Hospital Emergency Response Team (HERT) is not like the TraumaTeam, Cardiac Team or Stroke Team, which are designed to address routine“emergencies.”TheHERTisdesignedfordisasterorcrisisresponseforincidentsthatmayimpacthospitaloperationsbriefinduration(e.g.,explosion,fire,mul-tiplegunshotvictims)ormaybeprolongedoveraperiodofdaysorweeks(e.g.,floods,severeweather,pandemics).Forourpurposeswewilldefineacrisisasarapidlyoccurringeventforwhichtherearenotestablishedpolicies,proceduresorprotocols.

It isalsoimportanttorecognizethehealthcaresector’sfinancialclimatebal-ancedagainstthechallengesfacinghospitalsastheyattempttoimprovecrisisordisasterresponsecapabilities:

Medicaleconomicsintheglobaleconomiccrisis•Just-in-timeinventory•Remuneration•Lackofpreparednessassistance•Distractionofattentionbyadministrators,cliniciansandnursing•

Despite these challenges, hospital administrators must maintain a sense ofobligation to be prepared to respond to the community they serve, not just ona daily basis, but for the possibility of a once-in-a-lifetime event that will have

2 HOSPITALEMERGENCYRESPONSETEAMS

lasting impact on the facility’s reputation in its capture area. In essence, anycapability forahospital to respondon itsown,duringat least the initialphaseof a mass casualty event, is dependent upon secure leadership, not just havingthe staff complete a series of Incident Command System (ICS) classes. It is notenoughtodelegatecreationofaHERTprogramtothedirectorofplantengineer-ing, security, emergency management, or the emergency department withoutcontinuousengagementandsupportfromtheadministration.

Healthcare institutions have systems that allow them to integrate disparatehospital functions intoasinglesystemtoachieveacommongoalduringevery24-hour,7dayaweekoperatingcycle.Ahospital’ssystemwilltakeintoconsid-eration typical emergency operations, but oft times the structure breaks downwhenitcomestoorganizationalresponseformostofthelow-frequency,butquitepredictable,hazardsthatmayresultinmasscasualtyincidents.Thischapterwilladdressthosecomponentsthisauthorbelievescanprovidehealthcarefacilitieswith a means to establish a scalable incident management process that can beadaptedtoanyevent.

In the experience of this author, the components that contribute to an inci-dent being mitigated in the most efficient and effective manner (taking intoconsideration the available skill sets of employees and the totality of incidentcircumstances and operating conditions) are command, control, coordina-tion, communication and collaboration. If your incident management systemaccountsforeachofthesecomponents,youwillhavegivenyourstaff,patients,andsupportingagenciesthebestpossibleopportunitytodealwiththemajorityofeventsyourfacilitymayface.

We will explore each of these components to ensure there is clarity of themeaningofeach,withinthecontextofthisbook.Thisbookwasnotdesignedtotestyourknowledgeofincidentmanagementsystemsortheincidentcommandsystemspecifically; thisguide,alongwithadoptionofa trainingandeducationprogram,isdesignedtohelpyourHERTbecomeoperationallyproficient.TherearenumerousICScoursesavailableeitheronlineorinatraditionalclassroomset-tingifoneneedstopassatestaspartoftheirjoboraccreditationrequirement.Command PassinganICScoursewithaperfectscoredoesnotmakeyouthebestcandidate for the command position, nor does it make those around you safeduringacrisis.Whileseekingeducationisimportant,havingthepropertempera-ment,experience,commandpresenceandabilitytotransferclassroominforma-tionintopracticeiskey.ItisalsoimportanttorealizethatthepersonfillingthecommandpositionshouldnotnecessarilybetheChiefExecutiveOfficer,theheadofsecurity,orshiftsupervisor.Thisisnottosaythatanyoneoftheseindividualsis not competent to serve in the position of command, but they typically have

Chapter 1•CommandandControl 3

uniquepositionswithintheupperlevelsofmanagementofthehospitalitself.Itismuchmorebeneficialtobothcommandandthefacilityiftheseindividualsarefreefromcommandresponsibilitiesinordertocarryoutthetasksonlytheyhavetheauthoritytoaddress.Control Thebestwaytogainandmaintaincontrolistoslowtheeventdownforyourteambyestablishingsimple,clearandattainablegoals.Gainingcontrolmayrequire taking on numerous actions that encompass a host of issues. However,controlelementscanbebrokendownintoseveralgroupings,makingthemeasiertomanage.Physical Fixed Property The facility structure, parking lots, access corridors,adjacentbuildingcomplexesandutilityinfrastructureareallconsideredfixedprop-erty.Thegoalistoensurethestructureandallsupportservicesremainfunctional,aswellascompensateforthehigherdemandandincreasedloadthatwillbeplacedonthesystemwhenamajorincidentoccurs.Underthe“supportservicesremainfunctional”categoryyouwillalsohavetoensurethatsecurityaccessandcontrolproceduresareadequate,asfailuretoproperlycontrolthehospital’sfootprintasawholecan,andusuallydoes,resultinanuncontrolledandchaoticincident.

Figure 1.1 A fixed property that could be considered when selecting areas of security and control.

4 HOSPITALEMERGENCYRESPONSETEAMS

Equipment HERTequipmentcontrolandaccountabilityissuesarecloselyrelatedtothecurrentequipmentsystemutilizedbyyourhospital;theexceptionhereisthespecializedequipmentneededtofulfill theHERTmission.Suchequipmentmayonlybeusedduringtheincidentandmayormaynotbereturnedtoserviceafterward. Control measures may include ensuring the equipment is current,functional,operational,andaccessible.Arelatedcontrolmeasureisaccountabil-ityduringroutinechecks.Personnel A well-trained and practiced HERT provides the best command andcontrolelementwhenitcomestoorganizinganddeployingindividuals.Controlisconveyedbytheabilitytocommunicateclearandconcisedirectives,whichwillresultineffectiveoperationalgoalsbeingachievedwithlittle-to-noconfusionorconflict.Coordination Anyincidentthatisbeyondthenormalscopeofhospitalactivitiescreatesdisruptionandtaxesthesystem.AnincidentthatrequiresdeploymentoftheHERTwillobviouslyenhancethatlevelofdisruptionandproveachallenge.Coordination should be thought of on a multi-level, systemic approach; thescopeofwhatneedstobecoordinatedwithoutaffectingnormalhospitalopera-tionalneedswillinvolvecoordinationatahigh,“big-picture”level.Delegationof

Figure 1.2 Parking facilities can also be used for support services in an emergency.

Chapter 1•CommandandControl 5

dutiesandspanofcontrolremainthekeystonestoeffectivelycoordinatinglargeincidents.Communication Communications for a disaster incident should not get lostor confused with routine communication that occurs amongst hospital staff.The hospital setting already utilizes a specific and clear line of communicatingto ensure that proper and accurate information is communicated at all levelsofpatientandstaffoperations.Thisstrictyeteffectivecommunicationprotocolworkswellundernormaloperationsand isstillusefulduringaHERT incident,butthatiswherethesimilaritiesend.Duringanincident,notonlydoyouneedto communicate general information on a person-to-person basis, but you willmostlikelyhavetocommunicatetootheroperationalgroupsorteams,whichwilllikelyinvolveaportableradioorothercommunicationdevice.Addtothistheuseofpersonalprotectiveequipment,whichwillhinderdirectverbalcommunicationcapabilities,andhighnoiseenvironments,andyouhavethemakingsofacom-municationsnightmare.Communicationsat this level requirewell-thought-outcommunications equipment that is easy to use, easy to replace, and functionsthroughfortress-typewalls.Whenusingportabledevices,youmaywanttocon-sidersecuringmultiplechannelsifnumerousoperationalteamsareactivesimul-taneously; for instance,securityononechannel,HERTanother,supportonyetanother.Itmaybedifficult,inthemidstofanincident,tokeeptrackofnumerouschannelssimultaneously,soaradioliaisonmaybeofassistancehere;someonetoscanthechannelsandrelaypriorityinformation.

Communicationsshouldalsoencompasssharingpertinentorpriorityinforma-tionwithallteamsandhospitalstaffaffectedbytheincident.Indisasterincidentsituations,theadage“nonewsisgoodnews”doesnotapply;nocommunicationsornoinformationdoesnotalwaysequatetonothingbeingwrong.Communicatethe essentials and resist the urge to elaborate; provide clear, concise directivesandremainfocused.Collaboration Collaborativeeffortdoesnotjusthappen;however,collaborationcanbestbeachievedthroughjointpracticalexercisesthatallowallteammem-bers to understand the needs of all involved. Collaboration among the internalhospitalstaffmightbeassumed,butbearinmindthattheHERTmayindeedbecomprisedofmanyindividualsfromthehospitalwhorarelyhavetheopportunitytoworktogether,andthusareunfamiliarwithoneanother.

A second consideration for collaboration is among external entities such asambulance crews, fire departments, police/law enforcement, other mutual aidhospital staff, emergency management support groups or agencies, and newsmedia.Collaborationatthislevelrequiresjointpracticalplanning,exercisesandtraining,andrefinementofcommunicationspractices.

6 HOSPITALEMERGENCYRESPONSETEAMS

Itwillbehelpfultoreviewrecommendationsonthedevelopmentofaninci-dentcommandsystembytheNationalIncidentManagementSystem(NIMS)andtheHospitalIncidentCommandSystem(HICS).

History of Incident Command Systems DevelopmentCreationofIncidentCommandSystems(ICS)resultedfromtheobviousneedforanewapproachtothemanagementofrapidlymovingwildfiresintheearly1970s.Atthattime,emergencymanagersfacedanumberofproblems:

Toomanypeoplereportingtoonesupervisor.•Differentemergencyresponseorganizationalstructures.•Lackofreliableincidentinformation.•Inadequateandincompatiblecommunications.•Lackofastructureforcoordinatedplanningbetweenagencies.•Unclearlinesofauthority.•Terminologydifferencesbetweenagencies.•Unclearorunspecifiedincidentobjectives.•

Designing a standardized emergency management system to remedy theproblemslistedabovetookseveralyearsandextensivefieldtesting.TheIncidentCommandSystemwasdevelopedbyaninteragencytaskforceworkinginacoop-erativelocal,state,andfederalinteragencyeffortcalledFIRESCOPE(FirefightingResourcesofCaliforniaOrganizedforPotentialEmergencies).Earlyinthedevel-opmentprocess,fouressentialrequirementsbecameclear:

Thesystemmustbeorganizationallyflexibletomeettheneedsofincidentsof1. anykindandsize.Agenciesmustbeabletousethesystemonaday-to-daybasisforroutine2. situationsaswellasformajoremergencies.Thesystemmustbesufficientlystandardtoallowpersonnelfromavariety3. ofagenciesanddiversegeographiclocationstorapidlymeldintoacommonmanagementstructure.Thesystemmustbecost-effective.4.

Initial ICS applications were designed for responding to disastrous wildlandfires. It is interesting to note that the characteristics of these wildland fire inci-dentsaresimilar to thoseseen inmany lawenforcement,hazardousmaterials,andotherdisastersituations:

Theycanoccurwithnoadvancenotice.•Theydeveloprapidly.•

Chapter 1•CommandandControl 7

Unchecked,theymaygrowinsizeorcomplexity.•Personalriskforresponsepersonnelcanbehigh.•Thereareoftenseveralagencieswithsomeon-sceneresponsibility.•Theycanveryeasilybecomemulti-jurisdictional.•Theyoftenhavehighpublicandmediavisibility.•Riskoflifeandpropertylosscanbehigh.•Costofresponseisalwaysamajorconsideration.•

ICSisnowwidelyusedthroughouttheUnitedStatesbyfire-fightingagenciesand is increasingly used for law enforcement, other public safety applications,andforemergencyandeventmanagement.

FirstrespondershaveusedICSforanumberofyearstomanageincidentsofallsizes.TheBritishColumbiaEmergencyResponseManagementSystem(BCERMS)defines a process for organizing and managing a response to emergencies anddisasters based on a framework of five components: operations and control,qualifications, technology, training, and publications. The BCERMS is modularwithfourlevelsofoperation,includingsite,sitesupport,provincialregionalcoor-dination, and provincial central coordination.These four levels allow elementsto be activated or deactivated as the needs of the incident/emergency changeover time. The system also provides for expansion as additional resources arerequired.

Manyhaveaskedthequestion,“CanICSbeeffectivelyusedinahealthcareenvironment?” To answer this question, the Joint Commission (a healthcareaccreditationorganization,formerlytheJointCommissionontheAccreditationof Healthcare Organizations (JCAHO)) has studied a variety of disasters thathave impacted healthcare organizations. The Commission’s study involveddebriefingswiththeorganizationsimpactedbythesedisasters,discussionswithemergencymanagementexperts,serviceonnationalemergencymanagementpanels, and review of the contemporary emergency management literature.The disasters include floods, widespread extended electrical utility outages,wildfires, the terrorist attacks of September 11, the four back-to-back Floridahurricanesin2004,andHurricanesKatrinaandRitaontheGulfCoastin2005.Basedontheinformationgathered,theJointCommissionhasmadethefollow-ingdeterminations:

Duringacommunity-wideemergency,asingleeventcanescalateintomultipleevents. For example, Hurricane Katrina escalated to flooding because of failedlevees,andthefloodingfurtherescalatedintocivilunrestinsomecommunities.Therefore,itisnotsufficientthathealthcareorganizationsplanforasingleevent;rather,theymustdevelopthecapacitytorespondtocombinationsofescalatingevents.

8 HOSPITALEMERGENCYRESPONSETEAMS

Regardlessofthecauseofthedisaster,keyelementsoftheorganizationmustbeeffectivelymanaged.Theseincludecommunications;patientsafety;organiza-tion’sresources/assets,includingstaff;clinicalcare;andtheintegrityofbuildingutilities.Planningwithattentiontotheseelementsisintegraltoan“all-hazards”approachtoemergencypreparedness.

It is important that healthcare organizations consider, in their plans, thepotential fordisastersof longduration,suchasthosethatoccurredduringandaftertheFloridaandGulfCoasthurricanes.

During these events, the healthcare infrastructure became compromisedbecause healthcare organizations could not rely on their usual suppliers andresponsepartnersintheweeksthatfollowedtheimmediatedisaster.

Manyofthesameincidentcharacteristicsfacingfirstresponderschallengeourhealthcaresystemduringmajorevents.

History of Hospital Emergency Incident Command System

In 1987, the Hospital Council of Northern California completed work on theadaptationof the ICS tohospitalemergencyresponse functions inapublication

Figure 1.3 Hurricane Katrina and Hurricane Ike devastated the Gulf Coast and compromised numerous healthcare organizations.

Chapter 1•CommandandControl 9

entitled,EarthquakePreparednessGuidelinesforHospitals.ThatdocumentservedasacornerstoneinthedevelopmentoftheoriginalHospitalEmergencyIncidentCommandSystem(HEICS),writtenbyOrangeCountyEmergencyMedicalServicesin 1991 with a grant from the State of California Emergency Medical ServicesAuthority.In1992,OrangeCountyEMSbeganworkonthesecondeditionofHEICSwith funding provided by the State EMS Authority. This major rewriting of theHEICSwasdonewiththeintentionofmakingtheoriginaldocumenteasiertouseand implement within the hospital environment.The second edition attemptedto retain those same characteristics that made the original ICS-based plan soappealing.ThethirdeditionofHEICSwasproducedbytheCountyofSanMateoEmergencyMedicalServicesAgencywithagrantfromtheStateEMSAuthority.TheProjectbeganinthefallof1996withtheintentionofgatheringdataregardingtheusageofHEICS.Fromthisinput,arevisededitionofHEICSwascreated.The1998version,HEICSIII,rapidlybecamethestandardforhospitalemergencymanage-mentacrossthenation.

However, the world seemed to change on September 11, 2001. Some of theresponseissuesthatemergedonthosedaysincluded:

Lackofasystematicplanningprocess,withnopredictablechainof•commandLackofaccountability•Lackofcommonterminology•Poorcommunication•Incidentcommandersunabletokeepupwiththedevelopingsituation•Nomethodtointegratemultipledisciplinesandresponseagencies•Resultanthealthandsafetyissues,unnecessarydamage,ineffectiveresource•managementandeconomiclosses

Asaresultoftheterroristattacksandtheissuesassociatedwiththeresponse,anumberofsignificantpresidentialdirectiveswereissuedandtheDepartmentofHomelandSecuritywasformed.

AsaresultofHomelandSecurityPresidentialDirective5(HSPD-5),NIMS(theNational Incident Management System) was created in March of 2004.We nowhave a truly consistent, standardized, nationwide approach for federal, state,tribal, and local governments to work together to prepare for, respond to, andrecoverfromdomesticincidentsregardlessoftheircause,size,orcomplexity.

From the very beginning, local, state and federal agencies were expected tocomplywithpublishedguidelines.NIMSwasenvisionedto:

Provideaconsistenttemplateforgovernment,privatesector,andnon-•governmentorganizationstoworktogetherduringanincident

10 HOSPITALEMERGENCYRESPONSETEAMS

Promoteinteroperabilityandcoordination•Provideaflexibleframework•Addressallphasesofanincident,regardlessofsize,complexityandlocation•

TheNIMSOrganizationalDesigncomprisesthreelevels:

IncidentCommandSystem•Definesoperatingcharacteristics,managementcomponents,andincident•managementstructureforanincident

Multi-agencyCoordinationSystem•Defineshowsupportentitieswillbeintegratedandprovideassistance•

PublicInformationSystem•Processesandproceduresforcommunicatingtimelyandaccurate•informationtothepublicduringanemergency

NIMSprovidesacoresetofconcepts,principles,terminology,andtechnolo-gies that, when taken together, provide all responders with the tools needed toeffectively and efficiently manage a variety of incidents. NIMS consists of sixmajorcomponents:

Commandandmanagement•Preparedness•Resourcemanagement•Communicationsandinformationmanagement•Supportingtechnologies•Ongoingmanagementandmaintenance•

Hospital Incident Command System IV (HICS IV)

InOctober2004,theEmergencyMedicalServicesAuthority(EMSA) launchedaprojecttoreviewandrevisethecurrentversionofHEICS.TheHEICSIVprojectwas sponsored by the California EMS Authority, with contract support fromthe Washington Hospital Center Institute for Public Health and EmergencyReadiness (WHC IPHER) and Kaiser Permanente. HEICS IV was created by amulti-disciplinary 27-member national work group with representatives fromthe American Hospital Association (AHA), the American Society of ChemicalEngineers (ASCHE), the Joint Commission, the Department of Health andHumanServices(DHHS),andtheNationalIntegrationCenter(NIC).

TheHEICSIII,publishedin1998,servedasafoundationfortherevision.Therewas additional material review and input from a multi-disciplinary, approxi-mately 80-member secondary review group that included vendors. They were

Chapter 1•CommandandControl 11

taskedwithreviewingdraftmaterialsandprovidingcomments.Theentiregrouphadto:

Collaboratethroughface-to-facemeetingsandteleconferences•Buildaconsensusdocument•Updateandincorporatecurrentemergencymanagementpracticesintothe•systemEnhancethesystembyintegratingchemical,biological,radiological,nuclear•andexplosive(CBRNE)eventsintothemanagementstructureAddressanddevelopastandardizedconfigurationofHEICStoaddressrural•andsmallhospitalneedsDevelopastandardizedHEICSIVcurriculumandteachingaids(CDorvideo)•Developaninstructorcredentialingandcertificationprocesstoensure•standardizationinallhospitalsacrossthenationClarifythecomponentsofHEICSanditsrelationshiptotheNationalIncident•ManagementSystem(NIMS)

The HEICS IV project strove to ensure the applicability of HEICS in hospitalsacrossthenation.Inordertoaccomplishthatgoal, theHEICS(HICS)IVprojectcommitteemembershipincludedhealthcareprofessionalsfromacrossthenation.TheprojectcontinuestobefundedbytheStateofCaliforniaHospitalBioterrorismPreparednessProgramwithmoniesallocatedtotheStatefromtheHealthResourcesandServicesAdministration(HRSA)BioterrorismHospitalPreparednessProgram.As part of this project, HEICS was officially renamed simply HICS for HospitalIncidentCommandSystem.

Why Was It Called HICS?TheincidentcommandprinciplesembodiedinHICSareapplicabletoemergentandnon-emergentincidents.Thus,theletter“E”wasdroppedfromtheoriginalacronymtoreinforcethispracticalpointofimportance.“HEICSIV”isthenameoftheprojectthatledtothenewHICS.TheHEICSIVproject,fundedbyCaliforniaEMSAuthorityusingaHRSAgrant,resultedinthecreationofHICS.

HEICS vs. HICS

HICSisarevisionofHEICSIIIandis:

“Allhazards”indesign•Intendedfornon-emergencyevents,notjustemergencyincidents•Betterdesignedtobeusedbyanysizehospital•Morecompact,withascalableIncidentManagementTeam(IMT)design•

12 HOSPITALEMERGENCYRESPONSETEAMS

ContainsmodifiedJobActionSheets(JAS)•Composedofavarietyofotherplanningandresponsetools,suchas:•

IncidentPlanningGuides(IPGs)•IncidentResponseGuides(IRGs)•Forms•

TheHICSIVprojectteamembracedtheprinciplesofNIMSinthenewdocu-ment.PriortothereleaseofHICSIV,inamemorandumdatedMay26,2006,fromAlbert H. Fluman, Acting Director, NIMS Integration Center, DHS/FEMA, andCDRMelissaSanders,BranchChief,BioterrorismHospitalPreparedness,HRSA,HHS,hospitalswere informedthatNIMScompliancewasmandatoryforHRSAparticipation.

Ontheonehand,aneffectiveemergencymanagementsystemmustpermitateameffortfromthoseusedtorespondingtoemergencies.Ontheotherhand,itmustalsointegratethejurisdictionalneedsofthemunicipality’selectedofficials.Thesystemmust factor in the involvementof theseelectedofficials,whomostlikelyhave littleexperiencewithemergencyresponse,butwhomustultimatelyshouldertheresponsibilityforwhateverresponseoccurs.

Within Canada, there are three basic systems to manage disasters. Withinthesesystemstherearevariationsreflectingprovincialstandards,organizationalculture,andtoalesserdegree,thepreferenceofthosewhoemploythesesystems.ThesesystemsincludetheIncidentCommandSystem(ICS),theBritishColumbiaEmergency Response Management System (BCERMS) and the Emergency SiteManagement System (ESM). These systems have some common elements andsomeuniquefeatures.

TheIncidentCommandSystem(ICS)hasbeenaddressedearlierinthischap-ter and will not be covered here. The British Columbia Emergency ResponseManagementSystem,developedbytheB.C.governmentthroughitsInteragencyEmergency Preparedness Council (IEPC) is designed as a comprehensive “allhazards” provincial emergency operations system.This BCERMS identifies“thestandardized approach to emergency response management to be utilized andpracticed by provincial government ministries, agencies and crown corpora-tions.”BCERMSisbasedupontheIncidentCommandSystemasdevelopedandpracticedthroughouttheUnitedStates.Sincethefallof1992,theB.C.provincialgovernmentendorsed thisemergencymanagementresponsesystemandman-dateditsapplicationforallitsministries.

Site LevelAtthesitelevel,resourcesareutilizedtomanageproblemspresentedbyanemer-gencyincident.

Chapter 1•CommandandControl 13

TheBCIncidentCommandSystem(ICS)isusedtomanagetheresponse,usingresponders from all levels of government and the private sector. A single com-mandorunifiedcommandfromanon-siteincidentcommandpoststructureisutilized.

Site Support LevelWhenthesitelevelresponserequiresoff-sitesupport,anEmergencyOperationsCenter(EOC)maybeactivatedasasecondlevelofresponse.TheEOCsupportsthesitebyprovidingcommunicationwiththesitelevel,establishingpolicyguid-ance,managingthelocalmultipleagencysupporttothesite,aswellasacquiringanddeployingadditionalresourcesattheincidentsite,asrequired.

Provincial Regional Coordination LevelThisthirdlevelofactivationprovidesfurthersupporttothesitelevelorEOC,ifrequiredbyanescalationinthemagnitudeofemergency.Theprovincialregionalcoordinationlevelmanagestheassignmentofmultipleministryandagencysup-porttoindividualsitesupportlocationsormultiplesitesupportlevellocations.Itacquiresanddeploysrequestsfromthesitesupportlevelandprovidesemergency

Figure 1.4 Communications are an integral part of any emergency response.

14 HOSPITALEMERGENCYRESPONSETEAMS

responseserviceswhereincidentscrosslocalauthorityboundariesorwherelocalauthoritiesarenotorganizedtofulfilltheirrole.Thisregionalleveldoesnotnor-mallycommunicatedirectlywiththesitelevel,butrathercommunicatesthroughtheEOCorsitesupportlevel.

Provincial Center Coordination LevelThefourthlevelexiststoexpandsupport intoanoverallprovincialgovernmentresponse.Personswithinthislevelwouldhavetheresponsibilityfortheprovisionofsupportfortheregionallevels.Itiswithinthislevelofactivationthatauthorityoftheministerforadeclarationofaprovincialemergencyisobtained,directionofsenior elected officials is sought, and provincial policy and priority guidance isprovided.Thisgroupisresponsibleformanagingtheprovincialemergencypub-licinformationactivitiesaswellastheacquisitionanddeploymentofprovincial,federal,inter-provincialandinternationalresources.Ifrequired,thisgroupwouldprovidecoordinationandothersupportservicestoprovincialMinistryOperationCenters (MOCs)andCrownCorporation’scentersaswellasFederalemergencyresponseagencies.Thesystemisusednotonly inemergencysituations,but inprivate sector emergency response and management programs, as well as forplannedeventssuchascelebrations,parades,andconcerts.Itthusallowsmorepracticeandfamiliaritywiththesystemshoulditbeneededinanemergency.The“allhazards”approachinBritishColumbiaincludesfires,HAZMAT,multi-casualtyincidents,searchandrescuemissions,oilspillresponseandrecoveryincidents,andair,rainwaterorgroundtransportationaccidents.ItisalsoanintegralpartofBritishColumbia’searthquakepreparednessandresponseplans.

Canadian emergency services tend to receive training manuals and readingmaterialfromtheUnitedStates,wherethepoolofresourcesissignificantlylarger.Therefore,mostservicesareawareofandpractice,someformoftheICSsystem.AlthoughnotaswidelyusedorknownastheICSsystem,anotherapproachcalledEmergencySiteManagement(ESM)hasbeendocumentedforCanadiancommu-nitiesasaguideduringcommunity-widedisastersoremergencies.

Emergency Preparedness Canada (EPC) initially formulated the EmergencySiteManagement(ESM)systemintheearly1980’s.TheESMsystemstartedoutbeing a replica of the ICS approach. However, over time it developed its ownstructure,mandate,rolesandresponsibilities,tothepointthatitisnowaninde-pendentanduniqueapproachtothemanagementofdisasters,bothatthesceneandawayfromthesiteatthelocalEmergencyOperationsCenter(EOC).

The ESM unique approach is based on the Canadian system of emergencymanagement.Moreoftenthannotthatapproachplacesthefocusofemergencyplanning and disaster response squarely on the shoulders of municipal elected

Chapter 1•CommandandControl 15

officials who are ultimately responsible for the effectiveness of their municipalplansandresponseeffort.TheESMapproachconsidersandaddressestwoareasof operation: the site and the municipal EOC.The EOC is designed to containallkeydecisionmakerswhose inputmaybeofsignificancetotheoperationasawhole.Theirroleistosupporttheoperationaleffortatthescene,aswellastocarry on the day-to-day business of the rest of the community.While removedfromthescene(orsite),themembersoftheEOCareneverthelessofgreatvaluebecausetheyaretheformallinkbetweenthesiteandtherestoftheworld.

Disastersituations involvemanyorganizationsfromdiverse jurisdictions.Bythetimeacommunityrealizesit isconfrontingadisaster,ratherthanaday-to-day emergency that is manageable by emergency services alone, a number ofthingshavehappened.Variousagencieshavebeguntheirindividualresponsetotheincident.Thoseatthesitehavetriedtoworktogether.SomeoneassumedtheroleofaSiteManagercoordinatingeffortsatthesceneandacallmayhavegoneout toactivate theEOC.Onceactivated, theEOCpersonnel formallyappointaSiteManagerandadviseallrespondingagenciesofhis/heridentity(thispersonistypicallyrecruitedorappointedfromtheranksofthelocalfire,policeorEMSservices, depending on the nature of the disaster). From that point on, all keyfunctions at the site are typically coordinated through the Site Manager. Thisappointmentallowsincomingresourceagenciestohaveacontactperson.

TheSiteManagerhasachallengingrole.Heorshemustacceptthateverykeyagencyatthesitewillmaintainitsownchainofcommand,mandate,androles.Butatthesametime,theSiteManagermustcreatetheoperationalstructureatthescenethatwillprovideaneffectiveprocesstomanageinformation,delegateresponsibilitiesorresources,andcoordinateactionamongthediverseagencieson site. Additionally, the Site Manager must maintain a link between the sceneandthemunicipalEOC.Thisallowscommunicationtoflowfromthoseinvolvedintasksatthescenetotheirleadofficer,fromthatleadofficertotheoverallsitemanager,andfromthesitemanagertothemunicipalEOC.Theflowofcommu-nicationalsoworksinreversewhenbeinginitiatedfromtheEOCtothesite.

Inessence,everythingwithintheperimeterboundaryofthesiteistherespon-sibility of the Site Manager and the site team. This ‘team’ includes the seniorrepresentativesofthekeyagenciesaswellastheIncidentCommander,whocom-mandstheFireServicesresourcesat thescene.Thisgroup,undertheguidanceandcoordinationoftheSiteManager,managestheresponsetothedisastereventatthesite.

TheEOCteamisresponsibleforeverythingoutsidetheouterboundaryofthesite, such as coordinating with hospitals.The EOC team must also be availabletosupporttheoperationwithinthatsiteboundary,ifandwhenrequested.Roles

16 HOSPITALEMERGENCYRESPONSETEAMS

and responsibilities for the EOC team include media contacts, resource alloca-tion,integrationandcommunicationwithothercommunitiesandgovernment,and public information access. Such responsibilities are not far from the dailyresponsibilitiesoftheseelectedofficialsandallowforasmoothtransitionfromdailyoperationaltodisastermode.

TheESMsystemallowseachorganizationtoemploytheprocessthatbestfitsits needs, while still maintaining operational coordination and communicationbothatthesiteaswellasbetweenthesiteandtheEOC.Forexample,fireperson-nelcouldcontinuetousetheIncidentCommandSystemwithoutdetractingfromthe ESM process. Similarly, municipal officials are encouraged to employ theirownoperationalsystemandtomakestrategicdecisionsawayfromthechaosofthesite.Hospitalsmayusewhateverincidentmanagementstructuresuitstheirparticularneeds,suchasHICS,ICSorothers,butmustbeawareofandpracticecoordinationwith,theotheragenciestoensureeachfullyunderstandshowbesttoworktogether.Thereareessentiallythreesystemstomanagedisastersatcom-munity or municipal level currently utilized within Canada. The ICS system iswellknownbymost firstresponders inCanada,particularly those fromthefireservices.RespondersatsitelevelwhowishtomanageemergenciesandfollowanexistingchainofcommandfrequentlyusetheICSsystem.Becauseoftheirpriorknowledgeofthissystemanditsapplication,ICSoftenbecomesthepreferredordefaultsystemforlargescaleemergencies.Unfortunately,manymunicipaloffi-cialsmaynothaveexperiencewiththeICSsystemorbeawareoftheterminologyandintricatecommandstructureorreportingprocedures.

Theirlackofunderstandingcombinedwiththeiroverallresponsibilityforaneffectivedisastermanagementcouldleadtoconfusion,awkwardshiftsofcom-mandandcontrol,andultimatelyanuncoordinatedresponse.

The ESM model was designed to address this concern and clearly indicatesthe roles and responsibilities of municipal officials.The problem with this sys-temhowever, isthelackofregularexposuretotheprocess.Manycommunitiesandtheirdiverseagenciesdonotregularlyplanortrainfordisasters.Theirthreekey response agencies (i.e., fire, EMS, and police) plan and regularly train theirpersonnel.Theyalsohaveregularexposuretoemergenciesandtypicallyusethestructure(i.e.,ICS)thatsuitstheirrespectiveprofessionalneedsduring‘normal’emergencies.Whentheseemergenciesexpandtorequiremoreagenciestoworktogether, the three response agencies may be reluctant to switch to the ESMmodel.ThisreluctancemayoccurbecausetheESMsystemhasnotbeenproperlypracticedorduetoaninitialcommitmentatthesitetotheICSapproach.Withoutregulartrainingandpractice,hospitalswillalsobehardpressedtofunctionprop-erly.Intimesofstress,andmostdisastersarestressful,peoplereverttowhatthey

Chapter 1•CommandandControl 17

know or are comfortable with rather than try new methods. Consequently, theESMsystem,whichotherwisewouldassistincoordinationandcommunication,is leftuntried.Thismaybeparticularlyconfusingandfrustratingformunicipalofficialswhoarenotfamiliarwithanyoftheexistingrolesandresponsibilities.

BritishColumbiamayhavedevelopedasolutionto theproblembycustom-izingtheICSsystemto incorporatemunicipal leadersandgovernmentofficialswith the intention of providing harmony. Although the system should provideeffectiveemergencymanagementpracticeswithintheprovince inwhichitwasdesigned, it may cause significant conflicts in cross-border disaster situationswhenotherprovincesorstatesrespondbyusingothersystems.TheBCsystemalsorequiresfairlyextensivetrainingbyallthosewhowouldperformaroleinthevariouslevelsofactivation.

Inthefinalanalysis,anysystemwillworkifthereisanagreed-uponplanamongallrespondingagenciesandofficialstouseit.Beforeadisasteroccurs,ifeveryoneagreesonwhichprocesswillbeused,andistrainedinitsapplication,thesystemisvery likelytowork.Conversely,nosystem,nomatterhowwell-designed,willworkduringadisasterifthosewhoareresponsibleforoverallmanagementareunawareorunwillingtousethesystem.

Education and practice involving all those who would respond to disaster isessential.Effectivemodelsexistbutarenotuseful if theyarenotpracticedandunderstoodbyrespondersandgovernmentleaders.Trainingindisasterresponseat the community level is essential to ensure smooth transition from ‘normal’emergenciestodisasterresponsewithitsmulti-agencyeffort.

19

2Assessment of Likely Mass

Casualty Events and Potential Hospital Impact

Chapter ObjeCtives

To familiarize HERT members with the hospital response to mass casualty events (MCEs)•

Introduce the concept of surge capacity and how a hospital and HERT can increase a •hospital’s surge capacity

Introduce the “all hazards” approach to HERT preparation for MCEs•

Introduce the use of toxidromes for the management of chemical MCEs•

Provide a basis of knowledge to management likely types of MCEs, including chemical, •biological, radiological, and explosive (CBRNE)

Amasscasualtyevent(MCE),bydefinition,isapublichealthemergencyinvolvingmultiplepatientsthatoverwhelmslocalresources.Amasscasualtyeventmaysim-plybetheresultofamultiplevictimmotorvehicleaccident(MVA)wherethenum-berofpatientsreceivedatamedicalfacilityexceedsthatfacility’sabilitytoroutinelycareforthemoritcouldbeaterroristchemicalagentattack.AnMCEmaycompro-miseand/oroverwhelm,atleastintheshortterm,theabilityofalocalorregionalhealthsystemtodelivertheirnormallevelandnumberofservices.Thisoftenneces-sitatesatransitionfromwhatiscalledthe“standardofcare”toa“sufficiencyofcare”wheretypicalpracticesmaybealteredtomanagelargenumbersofpatients.

Historically,mostMCEsaretheresultofeithernaturaldisastersorlargescaleaccidentaleventswhichareobviouslynotplanned,buttheyalsoarenotunpre-dictable.Theseeventsdonottypicallyoccurwhenthehealthcareandemergencyresponsecommunitiesareattheready.Therefore,itisessentialthatthesecom-munitiesprepareaheadoftimesoastobeasreadyaspossible.

Theexceptionstotheconceptthatdisastersarenotplannedarethosedisas-tersthatresultfromterroristacts.Theseeventsaretypicallytheresultofextensivepreparationandplanningonthepartoftheterrorists.Historyhasshownusthatterroristsplantheirattackstocausethelargestnumberofcasualtiesaspossible

20 HOSPITALEMERGENCYRESPONSETEAMS

andtooccurwhenourcommunitiesareleastprepared(e.g.duringrushhouronacrowdedcommutertrain).Theymayoccuramidstalargegatheringofpeople,suchasasportingeventorconvention.Theymayalsooccurwhereandwhentheemergencyresponsesystemisleastpreparedtodealwiththem.

MCEstypicallyresultinasufficientnumberofcasualtiestooverwhelmexist-ingmedicalresources.AterroristMCEmayoccurinsuchafashionastospecifi-callyoverloadamedicalresponsecommunitywithinordinatelylargenumbersofvictims,targettheresponders,orexploitourlackofpreparednesstocreateaddi-tionalchaos.

A mass casualty event may be an obvious event such as a bomb blast.Instantaneous events such as explosive or chemical attacks are very recogniz-able and typically swift in producing large numbers of casualties. The closesthospitaltothiseventmaygetveryshortnotificationfromthelocal911system,fieldrespondersormayreceivenonotificationatall.Withoutawell-trainedandeffectiveHERTinplace,theyveryquicklymaybeoverwhelmedwithpatients.

Incontrast,anMCEsuchasabiologicalevent,whetheritisnaturally-occurring,accidental, or terrorist-invoked, may not have a sentinel event to forewarn themedical community that it has occurred. Examples of this include a pandemicfluthatresultsinmasscasualtiesincreasinginnumberovertimeorthereleaseofabiologicalagentthatproducescasualtiesonlyafteranincubationperiodofseveraldaysandthevictimshavedispersedand/ortraveledawayfromtheattacksite.LaterinthischapterwedescribethemnemonicD.O.C.T.O.R.asasimpletooltohelppersonneldeterminewhentoadopttheappropriateprotectiveposture.

Naturaldisastersarebyfarthemostcommoncauseofmasscasualtyevents.In North America, hurricanes, tornadoes and earthquakes are the most likelycausesofMCEs,whileelsewhereintheworldtheymayalsobeduetofloodsandtsunamis.

MCEs may include hazardous materials events such as train derailments. InNorth America an enormous quantity of hazardous materials is transported byrailonadailybasis.Therehavebeenmultipleeventsinrecentyearsthatresultedinlargereleasesofchemicalagentsintopopulatedareas.MCEsmayresultfromthe release of chemicals from fixed facilities as well. Such an event occurred inBopal,Indiain1984,resultinginthousandsofdeaths.Additionally,theTexasCityharborexplosionin1947resultedinhundredsofdeathsandthousandsofvictims.Thesetypesofeventsshouldbesourcesofstudyfor“lessonslearned”forthoseinvolvedinplanningemergencyresponse.

Other MCEs include building collapses and multiple victim MVAs, such asmultiplecarpileupsonhighwaysand/orbusaccidents.Pandemicinfluenzamayrepresent a global MCE incident. The infrequency of MCEs can create a false

Chapter 2•AssessmentofLikelyMassCasualtyEvents 21

THE TEXAS CITY DISASTER

OnApril16,1947,ashipcalledthe“Grandcamp,”afreighterthatwasloadedwithammoniumnitrate,dockedatTexasCity,Texas,caughtfireandexploded.Theresultantcourseofeventsfromthismassiveexplosionillustratesthesuddennessandlargeimpactthatamasscasualtyeventmayhaveonacommunity.Theresourcesofthelocalcommunitywerequicklyoverwhelmed.AlthoughmanyoftheneighboringTexascommunitiesrespondedbysendingassistance,thiswasduringanerawithnoadvancedsystemsfordisastermanagementandresponse.TheexplosionoftheS.S.Grandcampsetoffachainofrelatedexplosionsandfires,causinghundredsofdeathsandthousandsinjured(UnitedStatesCoastGuard,1947).

OncetheGrandcampcaughtfire,thefiredepartmentarrivedonthesceneandacrowdofpeoplegatheredtowatch.Thestandardplanfortowingadangerouslyburningshipfromtheharborwasnotimplementeduntilitwastoolate,andthetugboatdidn’tarriveintimetopulltheshiptosafety.Atalittleafter9:00a.m.theGrandcampexploded.Agreatcolumnofsmokeshotupanestimatedtwothousandfeet,followedtensecondslaterbyanother,evenmoreviolent,shockwave.Withinmomentsofthesecondblast,theMonsantoChemicalPlantwasinflamesresultingfrombrokenlinesandshatteredcontainers.Asentirebuildingscollapsed,trappingpeopleinside,firesquicklyspreadtotherefineriesthatmadeuptheTexasCityindusialcomplex.

Addingtothecatastrophewasaminiaturetidalwavethatwascreatedwhenwaterfromthebay,whichhadbeendrivenoutbytheexplosion,rushedinoverthedocksandcontinuedasfaras150feetinland,sweepingeverythinginitspathwithit.Alldaylongtheworkofcaringfortheinjuredandfightingthefirescontinued.Bynightfall,thetownwasfilledwithrescueworkersandambulanceshadmaderepeatedtripstoareahospitals.Rescueeffortscontinuedthroughthenight,evenasfearmountedbecauseanotherfreighter,alsoloadedwithammoniumnitrateaswellassulfur,hadalsobeenburningallday.Tugshadtriedinvaintotowheroutoftheruinedharbor.At1:10a.m.onApril17,theS.S.HighFlyerexplodedinthemostviolentofalltheblasts,takingwithheranothership,theWilsonB.Keene.Italsodestroyedaconcretewarehouseandagrainelevatorandtriggeredevenmorefires.Almosttheentirefiredepartmenthadbeenlostinthefirstexplosion,alongwithplantworkers,dockworkers,schoolchildren,andotherbystanders.

Thelossesfromthedisasterwereunprecedented:nearly600deaths,over2,000injuries,andpropertylossofover$67million.Dreadfulasthedisasterwas,itbroughtthepeopleofTexasCitytogetherasnothingelsehadeverdone.Thosethatremainedweredeterminedtorebuildandalloftheindustriesthatweredamaged,stayedandrebuilt.Itmustberememberedthatthedisasterwasnotcausedbyanindusialaccident,butbyashipinportthatexploded.Noonecouldhavepredictedthisunprecedenteddisaster.

22 HOSPITALEMERGENCYRESPONSETEAMS

sense of security in delaying preparedness initiatives until after another eventoccurs.It is likelywewillseemoreterroristattacksthatcreateMCEs,andifwechoose to not develop a robust HERT capability at our healthcare facilities theresultsmaybefatal.ThischapterwilllookatpotentialMCEcausativeagentsandhowhealthcarefacilitiescanprepareforthem.

Asnotedabove,terroristattacksarebydesignintendedtocauseasmanycasu-altiesaspossible.Theytargettheunpreparedaswellasstructuresandplacesthatmayhaveadditionalsymbolicand/orstrategicvalue.TheOklahomaCitybombingin1995targetedtheAlfredP.MurrahFederalBuilding,aU.S.governmentofficecomplexindowntownOklahomaCity,Oklahoma.Theattack,whichinvolvedanammoniumnitratetruckbomb,claimed168lives,including19children,andleftover800injured.Aroundthesametime,theAumShinrikyocommittedtwoter-roristattacksusingasarinnerveagent,inMatsumotoandTokyo,Japan,in1994and1995,respectively.Theseattacksresultedin19deathsandthousandsinjured,withseveralhundredrequiringhospitalization.

Mass shootings have often resulted in many victims.TheWestVirginiaTechshootings in 2007, were comprised of two separate attacks about two hoursapartontheVirginiaTechcampusinBlacksburg,Virginia.Seung-HuiChokilled32 people and wounded 25 before committing suicide, making it the deadliestshootinginmodernU.S.history.TheColumbinehighschoolshootingoccurredonApril20,1999,atColumbineHighSchoolinLittleton,Colorado.Twostudents,EricHarrisandDylanKlebold,carriedoutashootingrampage,killing12studentsandateacher,aswellaswounding24others,beforecommittingsuicide.

TheterroristattacksofSeptember11,2001,resultedin3,000deathsandhun-dredsmoreinjured.TheresponsetothiseventbylocalhospitalsisalsoasourceofstudyonthehospitalresponsetoalargeMCE.

Planning PracticalityHospitalsexisttotreatthemedicalconditionsandinjuriesoftheircommunities.ThismissiondoesnotchangeduringadisasterorMCE.Thegoalremainstomini-mizethesufferingofthoseinjuredand/orillaswellastosavelives.InanMCEthisgoalistemperedbytheneedtotriageahospital’sresourcestobestservemanypatientsatonetime.

Additionally,hospitaldisasterplanningmustprovideforthecontinuedcareofthosepatientsalreadyinthehospital,aswellasthoseinthecommunitywithmed-icalconditionsrequiringcare,notasaresultofthedisasterandMCE.Ultimately,thehospitalmaybeoverwhelmedbytheadditionalpatient loadresultingfromtheMCEbutwillnonethelessneedtomaintainservicesforthosepatientsalready

Chapter 2•AssessmentofLikelyMassCasualtyEvents 23

inhospital.HealthcarefacilitiesmustmakeplanstoinsurethattheycanmaintainoperationsduringandafteranMCE.Hospitaldisasterplanningshould includethesegeneralgoalsasabasisfortheirplanning.

Hospitalshavearesponsibilitybothtotheirstaffandtotheircommunitytobeprepared for disasters, and need to include MCE planning in their disaster pre-parednessplans.ProperplanninganddevelopmentoftheirHERTwillenhanceahospital’sabilitytorespondtoMCEssuchasachemicalterroristattackoranaturaldisaster(e.g.,earthquake)andalsoensurethesafetyofitsstaffduringtheevent.

Atabasiclevel,evensmallhospitalsmustdevelopatleastaminimallevelofpreparednesstoreceiveandtreatcontaminatedvictims.Thiswouldincludethedevelopment of procedures to be able to accept, decontaminate, and treat atleastonenon-ambulatorychemically-contaminatedpatient.Onceahospitalhasdevelopedtheabilitytodecontaminateandtreatonepatient,planningandtrain-ingtodecontaminatemanymorepatientsisachievable.

Hospitaldisasterpreparednessshouldalsoincludeplanstomanagethepoten-tialinfluxofmasscasualties.ThehospitalwillbethelocationwhereMCEpatientswillbetransportedforcare.Ifhospitalsarenotpreparedtoreceiveandeffectivelytreatthesepatients,littlewillbeaccomplishedotherthanrelocatingthedisasterfrom the scene to the hospital. Ideally, hospital disaster plans should integratewiththelocal,regional,andstatedisasterplansandresourcestobetterimprovethecommunity’sresponsetoadisaster.

Oneoftheinitialstepstodisasterpreparednessforahospitalistodeterminethe potential hazards it may face in its local community. A hazard and vulner-abilityanalysis (HVA) isa tool toscreen forpotentialhazards. It involvesasys-tematicapproachtoidentifybothinternalandexternalhazardsthehospitalmayface(seeChapter3).Moreimportantly,itstudiesthepotentialvulnerabilitiesthehospital may have to these hazards. Ultimately, this type of hazard analysis isbest done with a multi-disciplinary team that includes hospital administrators,subject matter experts (e.g., toxicologists, radiation safety officers), and otheremergencyresponderssuchashazardousmaterialsspecialists,infectioncontrolspecialists,industrialhygienists,emergencymanagersandplanners,andpublichealthpersonnel.ThegoalofthehazardandvulnerabilityanalysisistoenablethehospitaltobetterrespondtodisastersandMCEswhilecontinuingtoprovidecaretootherpatientsinthecommunityandprotecttheirstafffrompotentialhazardsandthreats.Althoughnotanewconceptinthefieldofemergencyresponse,thehazardandvulnerabilityanalysisbecameaJointCommission(formerlyJCAHO)requirementforhospitalsin2001.

“Plansmustbesimpleandflexible.Theyshouldbemadebythepeoplewhoaregoingtoexecutethem.”ThisquotefromGeneralGeorgeS.Pattontypifiesthe

24 HOSPITALEMERGENCYRESPONSETEAMS

approachthatshouldbeemployedforhospitalMCEplanning.Thecommittee(s)orgroup(s)doingtheMCEplanningforahospitalshouldincluderepresentationfromalldepartmentsorservicesthatwouldbeinvolvedinanMCEresponse.Forexample, administrative and executive officers of the hospital, physicians andnursingstaff,theemergencydepartment,pharmacy,securityandallotherstake-holderswouldbeneededtorespondtoanMCE.Ifallstakeholdershavehadinputintotheplan,itwilllikelybemoreachievableandeffective.

Abasiccomponentofanyhospital-basedMCEresponseplanisthatitshouldalwaysbeoperationalintermsofpersonnel(adequatelytrainedstaff)andequip-ment (available, functional with staff trained in its use). Hospital MCE plansshouldbeabletointegratewithexistingincidentcommandsystemsbothwithinthehospital(hospitalincidentcommand)aswellasexternalincidentcommandsystems,suchasthoseusedbyEMSandfiredepartments.Also,asaresultoffed-erallegislation,allhospitalsintheUnitedStatesmusthaveplanscompliantwiththeNationalIncidentManagementSystem(NIMS).

AsdisastersandresultantMCEstypicallyoccurwithoutwarning,hospitalMCEplans should be able to use existing personnel in the hospital for initial HERTresponseandincludemeanstoquicklyaugmenttheirpersonnel.Theplanshouldinclude provisions to protect employees from potential injuries and/or illness.ThisincludestrainingintheproperuseofPPEaswellaspoliciesandproceduresandinfrastructuremodificationstominimizestaffexposuretochemicalorinfec-tiousagents.Itshouldalsoincludestockpilingappropriateantibioticsforprophy-laxisagainstinfectiousagentsaswellasantidotesforchemicalexposure.

Overall,hospitalmasscasualtyeventplanningisacomplicatedbutcriticallyimportant task. Ultimately, a HERT must be able to balance the treatment ofmanypatientsagainstlimitedresources.Therefore,thegoalsandplanssetforthinahospitalMCEplanshouldbeachievableandcosteffective,butalsoadequate.Iftheoperationsaretobesuccessfulintheirimplementationtheymustalsobeefficient in their use of human resources. As much as other resources may belimited, hospital personnel to respond to the MCE are also likely to be limited.Therefore,theMCEplanshouldincludeasystemtotrainsufficientnumbersofstafftoallowforrotationofHERTpersonnelduringaMCE.

Additionally,ahospitalshouldincludetheuseofothercommunityresponseassets,ifavailable,toaugmentthehospital’sabilitytorespondtotheMCE.Priorplanning, such as establishing mutual aid agreements and training with otherlocalemergencyresponseagenciesand/orhospitals,isessentialifthisistobeareliablecomponentoftheplan.OftenthehospitalthatismostoverwhelmedinanMCEistheonethatisgeographicallyclosesttotheeventandnotnecessarilytheonethatisbestequippedtorespond.Therefore,otherhospitalsmaybeavailable

Chapter 2•AssessmentofLikelyMassCasualtyEvents 25

toshareand/orprovidefocusedresourcessuchasaHERT,specificmedications,orotherequipment.LocalEMS,policeandfiresystems,stateofficeofemergencymanagement, and local public health departments should be aware of thecapabilitiesandlimitationsofahospitalplan,suchthattheycanintegratetheirownresponsewiththatofthehospital.Thisintegrationisimportantforeffectivecommunication and coordination during the course of the MCE. Participationin Local Emergency Planning Committees (LEPCs) is highly recommended.Community-widecoordinationisbestaccomplishedthroughplanningaswellasregularandrealistictrainingbefore an event occurs.Awell-coordinatedresponseplanwillpreventwasteandinefficiencyandultimatelyimprovetheabilityforthehospitaltosavelives.

The simplicity of any response plan is often critical to its success. As a planbecomesincreasinglycomplexthelikelihoodthatitwillbreakdownandnotbefunctionalatthetimeitisneededincreases.Thisisapparentintherolesofper-sonnelinvolvedintheresponse.Ultimately,staffingaHERTrequirespersonneltoexpandtheirdutiesduringthecourseofanMCEresponse.Generally,personnelfunctionbestinfamiliarroles.ButbyexpendingtheefforttobuildupaneffectiveHERT,personnelwillbeassigneddutiesthataresimilartotheirnormalhospitalduties, and will have had specialized training that allows them to operate withincreasedsafetyduringanMCE.Economicallyspeaking,aswellasfunctionallyspeaking,yourHERTwilllikelyworkbetterifkeycomponentsarealreadyestab-lished, tested and well-known. Utilizing existing systems within the hospital asmuchaspossibleduringanMCEwillalsohelpkeeptheplanssimple.

Flexibilityisacriticalcomponentforanyall-hazards-all-threatsresponseplan.MaintainingsignificantflexibilityinthehospitalMCEplanallowsthehospitaltoeffectivelyadjust itsresponse(e.g.,smallvs. largeevent,chemicalvs. traumaticinjuries).Forexample,a flexibleplanmay includephasedresponses, such thata“lower” level of a disaster plan implementation is initially used. This type ofplanwouldincludeprocedurestobringinadditionalHERTresourcesasneeded,oras theconditionpermits, tostanddowntheHERTresponse inanorganizedand incremental fashion. Additionally, flexibility within the plan also allows fortheresponsetobeadjustedasadisasterevolves(e.g.,initialvictimsofaterror-ist attack have traumatic injuries due to a bomb, but subsequent victims havechemicalweaponpoisoningduetoachemicalsecondarydeviceandneeddecon-tamination).Flexibilityallowsforadditionaloutsideresponseassetstobeincor-poratedintoexistingHERToperationsastheeventchangesorincreasesinscale.

Coordination of a hospital disaster/MCE response reflects the ability of theHERTtoworkinanorganizedandefficientfashion.Inotherwords,personnelareabletocoordinatetheireffortssuchthattheresponseisefficientandmaximizes

26 HOSPITALEMERGENCYRESPONSETEAMS

the hospital’s ability to respond to the MCE.This may include simply knowingwhoisinchargeandknowingwhatyourroleisatthetimeoftheMCEresponse.Havingabasicunderstandingofwhateverybodyelse’sjobsintheHERTare,andhowtoworktogether,willalsoincreasetheefficiencyoftheteam’sresponse.

Leadership is the key component of any plan. In the hospital setting, theHospital Incident Commander (HIC) has the authority and responsibility ofcoordinating the hospital’s overall MCE response. The HERT Commander isresponsible for the team’s actions. The individuals in leadership roles must befamiliarwithallaspectsofthehospital’sMCEplanbeforeaneventoccurs.ThisisessentialastheHICisbestabletocoordinatetheresponseonlyifheorshehasanadequateunderstandingoftheassetsavailable,aswellasthecapabilitiesandlimitationsoftheHERT.TheHICisacriticalpositioninahospitalMCEplan,buttheHERTCommanderisoftenpivotal indeterminingthesuccess,orfailure,oftheemergencyresponse.

Overall,theHICbestservesthisrolebyremainingcalmandeffectivelydirect-ingtheresponseoftheentirehospital.Thismayinvolvedealingwithmanyper-sonnel and/or agencies both within and outside the hospital. The HIC shouldbe able to clearly and concisely direct personnel regarding coordination of thehospitalMCEresponse,continuallyre-evaluatethesituationasaneventevolves,andreorderprioritiesdependinguponchangingneedsduringthecourseoftheresponse. The HIC must effectively delegate certain operational functions andtaskstobestcoordinatethehospital’sresponsetotheMCE;allowingtheHERTtofunctionasdesignedandtrainedwillbecritical.

Communicationisoftenthemostcriticalfunctioninanyresponsetoalargedisasterorevent.Itisalsoconsideredthemostvulnerabletofailureinanydisasterresponse.Duringdisastersthecommunicationsystemswithinasmallcommu-nity can be quickly overloaded. Additionally, the communication infrastructurealsomaybecomeinvolvedinthedisasterandbecompromised,furthermakingcommunicationdifficult.Communicationplansforthehospitalshouldberedun-dantandbeintegratedwithsurroundingagencies.Theyneedtobeevaluatedonaperiodicbasistomakesuretheyarebothoperationalaswellasinteroperationalwithoutsideagencies.Thebestguaranteeofsuccess for theHERTin theeventof predictable communication failures is achieved through repetitive training,whichleadstoquietconfidenceinstaffbeingabletoperformtheirtaskswithoutcommunicationadjuncts.

Insummary,hospitalMCEplanningshouldbebasedonlearningtheprinciplesofdisasterplanningandmanagementinawaythatthehospitaldevelopsaplanthatcanbeappliedtoanysituation.Abasic,robustandflexibleHERTcapabilitythatisfocusedonagenericmasscasualtyresponsecanbeaugmentedtorespond

Chapter 2•AssessmentofLikelyMassCasualtyEvents 27

tospecifictypesofMCEssuchaschemical,biological,ornuclearattacks,aswellasnaturaldisasters.

Hospitalsurgicalcapacityisanimportantcomponentofahospital’sabilitytorespondtoaMCEandcanbemeasuredinmultipleways.Thehospital’shumanresourcesand/orpersonnelarepartofthesurgicalcapacity;thisincludesmedi-calcareproviderssuchasdoctorsandnursesandthemanyspecificjobtypesandskillsthatareessentialand/orcriticaltotheefficientandeffectiveresponsetoaMCE.AhospitalMCEresponseplanshouldidentifyspecificjobsandcriticalposi-tionswithinthehospital thatwillbeessential foranMCEresponseandensurethesepositionsarefilledwhenaMCEoccurs.

Equipment,bothdurableanddisposable,mayverywellbecomearate-limitingfactorinahospital’sabilitytorespondtoanMCE(e.g.,mechanicalventilators).Other disposable supplies such as endotracheal tubes, intravenous supplies,bandages,andotherburnortraumasuppliesarealsoessentialaspectsofsurgecapacity.Furthermore,surgicalcapacitycanbedeterminedbytheinfrastructureofthehospital(e.g.,thenumberofoperatingorisolationrooms).Pharmaceuticalsuppliesarecertainlyacriticalaspectofahospital’sabilitytorespond.Thismayinclude specific medications such as antidotes for nerve agent or cyanide poi-soning,andantibiotics.Thesurgecapacityofahospital’spharmacycanbeaug-mentedboththroughstockpilingofspecificmedicationsand/orimplementationofprocedurestobringexternalsuppliesofpharmaceuticalsorpharmacistsintothehospitalintheeventofanMCE.

Ultimately a hospital will reach a finite bed capacity to treat patients. Thisaspectofsurgecapacitycanbestbeaddressedbytheestablishmentofagreementswithalternatecarefacilitiesthatthehospitalmaybeabletodivertand/ortransferpatients to for care. A properly trained HERT triage team working at the initialreceptionpointwillbedecisive in thehospital’sability tomaintain throughputofpatientsovertime.NotunliketheNationalDisasterMedicalSystem(NDMS),ahospital’ssurgecapacitywouldbeaugmentediftherewereplansandproceduresinplacetorouteortransferpatientstootherfacilitiesasappropriate,allowingthehospitaltocontinuetoreceiveandtreatnewpatients.ThiswouldbeimportantinprotractedMCEs,suchasabiologicalweaponsattack,thatcontinuetogeneratenewpatientsoveralongerperiodoftime.

Stockpiling of PPE for surge response staff requires careful considerationandshouldbe included inanyhospitalMCEresponseplan.Additionally,somerespiratorsandPPErequirefittestingandtrainingtobeusedsafelyandeffectively,whichwillhavetobeaccomplishedbeforeanMCEoccurs.SufficientPPEmustbeonhandtoallowforhands-ontraininginthePPE,andoperationalefficiency,confidence,andsafetyforallpersonnelanticipatedbeingapartoftheHERT.

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Chemical, Biological, Radiological and Explosive ThreatsThefollowinginformationis includedinthistext,asHERTmembersare inthebestpositiontobecomesubjectmatterexpertsinrecognizinganddealingwithunconventional threats.Allowingapatient into the facilitywithoutappropriaterecognition of the threat can lead to delays in detection and containment, andpossiblyresultinunnecessaryexposureofotherhospitalpersonnel.

Chemical Threats

The possibility of an MCE resulting from the release of a toxic chemical com-poundisrelativelyhighgiventhehistoryofsuchevents.Therehavebeennumer-ousinstancesinwhichthereleaseoftoxicchemicalcompoundshassentpatientstothehospital.Moreoftenthannot, thesereleasesresult inonlyafewvictims.However, a large chemical release involving a vapor or a gas may result in anMCE.Thecharacteristicsofthevapororgasareimportant.Specifically,heavier-than-airgaseswillremainclosetotheground,inthebreathingzoneofpotentialvictims.Thereleaseofchemicalsmaybeaninsidiousevent,suchasthefailureofatankfitting,oritmaybeanexplosiverelease,suchasanuncontrolledchemicalreactionresultinginthefailureofapressurizedvessel.Theexplosiveeventmightbefromsabotagedesignedtoreleasethecompound,oraneventprecedingtheintentionalreleaseofthechemical.SuchtacticshavebeenusedrecentlyinIraq,wherecarbombshavealsocontainedchlorinetanks.

Additionally, mass casualty events involving a chemical release may involvethehospitalitself.Ifthereleaseisofsignificantmagnitude,thechemicalplumemayenvelopethehospitalandmaycomprisethathospital’sability torespond.Forinstance,inJanuary2002,TrinityhospitalinMinot,NDwasenvelopedbyacloudofanhydrousammoniathatblanketedtheentirecityafteranearbytrainderailment.Thehospitalitselfmightbetargetedbyaterroristeitherasaprimaryorasecondarytarget,inwhichcaseastrongHERTsecuritycapabilitytocontrolaccesstothehealthcarefacilityisimportant.

AchemicalreleasecausinganMCEislikelytobequicklyrecognized.Veryoftenpatientswillself-evacuatefromthesceneandmayarriveatthehospitalpriortothehospitalevenbeingnotifiedoftheevent.Typically,thenearesthospitaltotheeventisoverwhelmedbypeopleescapingtheexposureandseekingthenearestsourceofmedicalcare.ThiswasthecaseduringthesarinnerveagentreleaseinTokyoin1995whenSaintLuke’shospitalreceivedhundredsofpatientswithinanhouroftherelease.

Chapter 2•AssessmentofLikelyMassCasualtyEvents 29

Victims of a large chemical release may vary widely in their severity ofpoisoning, from the critically ill to the “worried well.” Paradoxically, the moreseverely affected victims will reach the hospital later than less affected victims.Thisisbecausemildlyormoderatelyaffectedvictimswilltypicallyself-evacuateand be en route to the hospital prior to EMS arrival at the scene. Statistically,as many as 70–85% of victims will arrive at the hospital without the assistanceofEMS.

IntheTokyosarinattacks, largenumbersofvictimsarrivedatareahospitalsfromthescenewithoutclinicallysignificantpoisoningand/orevenevidenceofexposure.Thesevictimsareoftenreferredtoas“psychologicalcasualties.”Theymaynotrequiremedicaltreatment,butwillcertainlyimpacthospitalresponseastheywillstillneedtobemedicallyscreenedanddispositioned,whichwillslowthedeliveryofcaretothosevictimsinneedoftreatment.Therefore,theHERTrecep-tionareashouldconsiderlargenumbersofpsychologicalcasualtiesintheirplans.Proceduresshouldbemadeforthesepatientstobeevaluatedquicklyandmovedthroughthesystemasexpeditiouslyaspossible,sothatthehospitalcanprovidecareforothermoresignificantlyaffectedvictims.

Often, plans for responding to MCEs resulting from large chemical releasesinvolvedevelopinglistsofchemicals.However,itisveryimportantforthebasicHERT MCE plan not to be driven by such lists. Response protocols should bebasedonrespondingtoanunknown,undifferentiated,andundiagnosedchemi-calexposure.Theplancanthenhavedifferentbranchesthatcanbeemployedasinformationbecomesavailable.Thereare,however,acertainnumberofchemi-calsthatareofhighertoxicityand/orrequirespecifictreatmentthatneedtobespecificallyconsideredinthehospitalMCEresponseplans.Ingeneral,chemicalMCEresponseplansshouldincludespecificprovisionstorespondtochemicalsthatareknowntobeweaponizedaschemicalwarfareagents(suchnerveagentsthatrequireantidotes)ortoxicchemicalsknowntobestoredwithinthecommu-nity.

Therearealsonumeroustoxicindustrialchemicals(TICs)andtoxicindustrialmaterials (TIMs) that representasignificant threatdueto theiravailabilityandpotentialtobeusedaschemicalweaponsofopportunity.Inshort,chemicalsthatareofconcernwouldincludethosethatareavailableinlargequantities,availablelocallyandhavehightoxicity.TheriskofthesechemicalscausinganMCEshouldbeassessedwithahazardandvulnerabilityanalysis(HVA)donebythehospitalin conjunction with the surrounding community. Any chemical with sufficienttoxicity,availabilityandquantitycancauseanMCE.

In as much as the HERT response protocols for a chemical MCE should beflexibleandgeneralenoughtorespondtoanypotentialchemicalrelease, there

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arecertainchemicalsthatwouldrequireearlyidentificationtooptimizemedicalmanagementandsurvivalofthevictims.Thesewouldbechemicalsthatrequireaspecificantidoteand/orspecifictreatments,suchasnerveagents,organophos-phatepesticides,orcyanide.ShouldahazardvulnerabilityanalysisofahospitalanditscommunityrevealchemicalsthatmaycausealargeMCEatthathospitalandrequirespecificantidotaltherapy,thenthathospitalshouldplantoStocktherequiredtreatmentand/orantidote.

Chemicalagentsthatcouldbeencounteredinaterroristattackorinanacci-dentalchemicalreleasesharesomedegreeofoverlap.Chemicalwarfareagentstypicallyincludenerveagentsand/orvesicantagents.Inthepasttheyhavealsoincludedagentssuchaschlorine,phosgeneandcyanide.TheseagentshavebeenabandonedasviablechemicalwarfareagentssinceWWI.However,theyarestillfoundin largequantities in industryandinourcommunitiesandmaybeusedaschemicalagentsofopportunityforaterroristattackorcouldbeaccidentallyreleased.Forinstance,therearenumerousreleasesofanhydrousammonia,chlo-rineandotherchemicals inourindustriesannually.Althoughveryfewoftheseresultedinanylargenumberofexposedvictims,itdoesdemonstratethefactthathighly toxic chemicals are still available and somewhat ubiquitous.The impor-tanceofthisisthefactthattherearenumerouschemicalweaponsofopportunityinourcommunitiesthatmayresult inchemicalMCEsandyourHERTmustbepreparedtobeeffectiveandsafe.

ManychemicalMCEsaretheresultofachemicalthatisnotreadilyidentifiableat the time of the victims’ presentation to the hospital. Indeed, the sarin nerveagent released in the Tokyo subway in 1995 was initially mistakenly identifiedasacyanidecompound.Therefore,itisimportantfortheHERTtodevelopandpracticeachemicalMCEresponseplanbasedonthelikelihoodthatthechemicalwillnotbeidentifiedatthetimeevent.Moreover,mostchemicalexposurescanbe treated with supportive care without specific identification of the chemical.Medicalmanagementincludesairwayandrespiratorymanagementperadvancedlifesupportprotocols.Furthermanagementcanbetailoredasthepatient’scondi-tionchangesand/orspecificinformationaboutthechemicalbecomesavailable.

BasicchemicalMCEHERTresponseprotocolsmaybeaugmentedbyspecificprotocolsorproceduresforchemicalsthatareknowntobeinthathospital’scom-munity.EmergencyplannerscanutilizetheEmergencyPlanningandCommunityRighttoKnowAct(SARATitleIII)toobtaininformationabouttheindustriesinthehospital’sareatoidentifyspecificchemicalsthatmaycauseachemicalMCE.Additionalplansmayincludethestockpilingofrelatedantidotes.Itmaybehelp-fultodevelopspecificproceduresandprotocolstointegratetheHERTresponsewiththelocalindustrythatmaybeusingthosechemicals.

Chapter 2•AssessmentofLikelyMassCasualtyEvents 31

Insummary,itisimportantfortheHERTMCEresponseplannottobebasedonalistofchemicals,buttobebasedonabasic,robustandflexiblechemicalMCEresponseplan.Additionalspecificresponsesbasedonwhatchemicalsmightbefoundlocally,orotherchemicalsthatrequirespecifictreatmentorantidotes,canbeannexedtothisbaseplan.

ToxidromesAnessentialclinicaltoolforthediagnosisandmanagementofchemicalexposuresistheuseoftoxidromes.Bydefinition,atoxidromeisaconstellationofclinicalsignsand/orsymptomsspecifictoaparticularchemicaloraclassofchemicalsordrugs.Theyareusefultohelpdiagnosetheresponsiblechemicalordruginanintoxicatedpatient.Commontoxidromesincludeopioid(alsocalledtheopiate),sympathomimetic,sedative-hypnotic,cholinergicandanticholinergic.Therefore,the HERT chemical MCE response should include training of personnel on theteamintheuseoftoxidromestorapidlydiagnoseandtreatundifferentiatedpoi-sonedpatients.Aworkingknowledgeoftheuseoftoxidromeswillhelpahospital-based provider to diagnose and treat based on the clinical presentation of thepatient,orpatients,withoutidentificationofthecausativedrugand/orchemical(whichcouldbedelayed).

Toxidromes,asmentionedabove,areaclinicalcollectionofsignsandsymp-tomsthatcanbeassessedbyanexaminer.Theclinicalevaluationtodetermineatoxidromeincludes:aqualitativeassessmentofvitalsigns,assessmentofpupils(dilated or constricted); respiratory status (hyperventilating, hypoventilating orsomedegreeofrespiratorydistress);neurologicalstatus(depressedneurologicalsystem such as coma or unresponsiveness or a stimulated neurological systemsuchasseizuresoragitation);skin(dryordiaphoretic)aswellasotherspecificclinicalsignsandsymptoms. It is importanttonotethataspecificpatientmaynothaveeveryfeatureofatoxidrome.InaMCE,manypatientsmaypresentwithsimilar clinical findings that may not be completely consistent with a specifictoxidrome.However,whenallthepatients’presentationsareconsideredinaggre-gatetheymayleadtoaclinicaldiagnosisandpotentiallytheidentificationofthechemicalresponsibleaswell.

The opioid toxidrome is what we would expect to see from someone intoxi-catedonnarcoticsoropiates.Ittypicallyisexemplifiedbydecreasedmentalsta-tuswhichmayrangefromcomato lethargy,constrictedpupils,anddepressed,shallow,orapneicrespirations.Thepatientmayalsohavebradycardia,decreasedbowel sounds or hypothermia. The essential symptoms of decreased mentalstatus,decreasedrespiratorystatusandconstrictedpupilsare themostconsis-tentpresentationofthistoxidrome.Opioidsarenotoftenconsideredtobealikely

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causeofanMCE.However,onOctober23,2002,morethan800peopleattendingaplayinMoscowweretakenhostagebyabout50Chechenrebels.Afterseveraldaysofahostagestandoffandfearsthattheterroristswouldsoondetonatetheirexplosives,theRussianmilitaryintroducedanincapacitatingchemicalagentintothetheatre,whichcausedcomaandrespiratoryarrest intherebelsaswellasalargenumberofthehostages.Theendresultwasthatoutofthe800hostages,127actually died of exposure to this agent, which was later identified as a fentanylderivative.Thisisanexampleofamasscasualtyeventresultingfromtheuseofanopioidcompound.

The cholinergic toxidrome is the presenting toxidrome of a nerve agent ororganophosphate pesticide poisoned patient. It is a direct result of excess ace-tylcholinebindingtoacetylcholinereceptors inthecentralnervoussystem,theautonomic nervous system, and at the neuromuscular junction. Muscarinicmanifestationsofnerveagentpoisoningincludeexcessexocrineglandsecretionsandsmoothmusclecontraction.Theseeffectsareoftensummarizedinthemne-monicsSLUDGEorDUMBELSwhichinclude:salivation,lacrimation,urination,gastrointestinaldistress,defecationordiarrhea,emesis,bronchoconstrictionandbronchorrhea,andmiosis.Paralysisoftheskeletalmusclesofrespirationandthediaphragm worsens muscarinic-mediated respiratory bronchorrhea and bron-choconstrictionandcanrapidlyleadtorespiratoryarrest.TheinterestedreaderisencouragedtofurtherstudytheconceptoftoxidromessuchthatHERTteammembers may be familiar with toxidromes and may use them in the event ofanMCE.

In managing a chemical MCE it is important for the HERT to keep focusedon an all threats, all hazards approach. By HERT members maintaining a widedifferentialdiagnosiswhenpresentedwithavictimofchemicalagentexposure,thepatient ismore likely toreceive life-saving intervention ina timely fashion.Treatmentshouldbebasedontheclinicalpresentationofthepatient.Regardlessoftheactualchemicalagentinvolved,treatmentprioritiesremaintheABCs(air-way,breathing,circulation).Ifatoxidromethatrequiresanantidoteisidentified,then the antidote can be administered as well. Although ultimately important,identificationoftheactualchemicalreleasedmaynotimpacttheemergenttreat-mentonthepatient’sinitialpresentation.

Care in the HERT treatment area should be tailored appropriately as addi-tional information becomes known and/or certain determinations as to thepatient’sconditionaremade.Forexample,shouldinformationbecomeavailablethat the patient was exposed to cyanide then the appropriate cyanide antidoteshouldbeimmediatelyadministered.Additionally,asdiagnosesaremadeinthehospital they should be communicated to the other responding agencies such

Chapter 2•AssessmentofLikelyMassCasualtyEvents 33

that the information can be shared with other hospitals and/or utilized in thepre-hospitalsettingaswell.Thevalueoftoxidromesandthesharingofinforma-tion is illustratedby the fact that in the1995Tokyosubwayattacksaphysicianwhohadtreatedvictimsofthe1994Matsumotosarinnerveagentattack(andwaswatchinglivetelevisioncoverageofvictimsarrivingathospitals)recognizedthecholinergic toxidrome and called the hospitals to notify them that it was nerveagentthattheyweredealingwith.

Uptothispoint,theemphasishasbeentheall-hazards,all-threatsapproachtomasscasualtyeventresponse.ThishasbeenthecasewiththechemicalMCEresponseaswell.However, thereareanumberofchemicalagents thatdeservespecificattention.Theseagentshavehightoxicity,maybemorereadilyavailable,ormaybeavailableinlargerquantitiesandthereforemorelikelytobeencoun-tered as the cause of a chemical MCE. Some of these are known to have beenweaponized, such as nerve agents, and some require specific antidotes, suchas nerve agents or cyanide.Therefore, the following sections should serve as aprimerforHERTteamstodevelopaknowledgebaseaboutpotentialagentsthatcouldcauseMCEs.Alargenumberoftoxicindustrialchemicalsareclassifiedasirritantgasesorpulmonaryagents.Theseincludechlorine,anhydrousammonia,phosgene and others. The pathophysiology of the lung injury caused by thesegases is determined by the physical characteristics and chemistry of the gas.Thosegaseswithhighwatersolubility,suchaschlorine,willirritatethemucousmembranesoftheupperrespiratorytract,providinganoxiouswarningpropertyto these gases. Other gases with poorer water solubility often will not interactquicklywiththemoisturefoundintheupperairwaysandinsteadpenetratedeepintotherespiratorytract,causingasignificantamountof injury inthedistalorlowerairways,suchasthealveoli.

Oftenthesegasesgenerateanacidoranalkalinethatwillreactwithandinjuretissue.This could lead to upper airway edema and airway compromise leadingtoasphyxiation.Inthelowerairwaystheycancausetissueinjuryatthelevelofthe alveoli, resulting in a non-cardiogenic pulmonary edema (often delayed),possiblyleadingtoasphyxiation.Pulmonaryagentscanalsobeveryirritatingtothe smooth muscle that lines the respiratory tract and may cause a significantamountofbronchospasmaswell.

ChlorineChlorinehasgoodwarningcharacteristics,suchasagreen-yellowishcloudandaverypungentandwell-recognizedodor.Itbecomesagasatanambienttempera-tureof34°Candwilllikelybeinagaseousstatewhenreleased.Itsvapordensityis2.5comparedtothatofair(1.0).Therefore, itwilltraveldownhillandremain

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closetotheground,settlingingeographicaldepressions.Itisheavilytransportedandtypicallyshippedasaliquefiedpressurizedgas.Itishighlyreactivewithmanycompoundsandcanreactexplosively.Thesecharacteristicsmakeitagoodcandi-dateforuseasachemicalweaponofopportunity.ThiswasthecaseinIraqfrom2006to2007whennumerouscarandtruckbombsweredetonatedwithchlorinetanksinthevehicles.

Chlorineisaubiquitouschemicalfoundinmanyplacesaroundourcommu-nities.Itcanbefoundatfixedfacilitiessuchaswatertreatmentplantsandotherfacilitiesthatutilizechlorineinlargequantities.Importantly, itcanbefoundintransit,eitheronthehighwaysorinrailcars.AnimportantaspectofalocalHVAistodeterminewherefixedfacilitiesmightexistinthecommunityaswellaslocaltransportation routes. Identify possible or most likely sites for chlorine release,duetoeitherarailcarderailmentand/oraterroristattackonrailtankcarscar-ryingchlorine.

When chlorine interacts with water found in the mucous membranes it willform hydrochloric acid. This hydrochloric acid subsequently interacts with thetissues, causing mucous membrane irritation at low levels and tissue necrosisat high levels. This interaction is also responsible for the characteristic effectsof chlorine including irritation of the eyes, nose, and throat, causing coughing,laryngospasm and bronchospasm. At higher concentrations chlorine will reachtheperipheralairwaysoftherespiratorytract.Intheperipheralairwaysasecondchemicalreactionoccursthatgeneratesoxygenfreeradicals.Thesefreeradicalsattack the alveolar-capillary membrane, producing non-cardiogenic pulmonaryedema.

After initial assessment and decontamination, treatment priorities includeairway and pulmonary management. Aggressive airway management is impor-tant given the possibility of progressive upper airway edema leading to airwayobstruction.Managementof lowerairwayinjuryincludestheadministrationofoxygen,bronchodilatorstotreatbronchospasm,andsupportiveICUcarewithorwithoutmechanicalventilation.Lessseverelyinjuredpatientsmaybeobservedandputatbedrestpendingresolutionoftheirsymptoms.Itshouldbenotedthatvictimsofchemicalagentinhalationinjuryshouldbeobservedforlatentsymp-tomssuchasnon-cardiogenicpulmonaryedema.

PhosgenePhosgenewasaWorldWarIchemicalweaponandiswidelyusedinthechemi-calindustryasanintermediateforchemicalsynthesessuchastheproductionofdiisocyanates for polyurethane production. Phosgene is a highly toxic gas withanOSHAimmediatelydangeroustolifeandhealth(IDLH)limitof2ppm.Itisa

Chapter 2•AssessmentofLikelyMassCasualtyEvents 35

colorlessandhighlytoxicgaswitharelativelyinnocuousodor.DuringWWI,whenitwasintroducedasachemicalweapon,soldierswereoftencautionedtobealertfortheunexplainedodorofmownhayorgrass.Thissmell,althoughcharacteris-tic, isnotterriblyoffensive,lackingthewarningpropertiesnotedwithchlorine.This is primarilydue to its poor water solubility compared to chlorine. It has avapordensityof3.4,andwhenreleaseditwillremainclosetotheground,travel-lingdownhillandintogeographicaldepressions.

Phosgene,asmentionedabove,isacommonchemicalintermediate.Avastmajorityofthis isusedfortheproductionof isocyanates,whichsubsequentlyare used for the production of polyurethane as well as pesticides. Althoughit may be shipped as a liquefied, pressurized gas, 99% of phosgene is utilizedonsitewhereitwasproduced.Therefore,itislesslikelytobeahazardintransit.Nonetheless, a community threat assessment should determine whether anyfixed chemical facilities within the area indeed manufacture and/or stockpilephosgene.

Although poorly water soluble, in high enough concentration phosgene willinteractwithwaterinthemucousmembranestoliberatehydrochloricacid,simi-lartothechemicalinteractioninwhichchlorineproduceshydrochloricacid.Duetoitspoorwatersolubility,mostinhaledphosgenereachesthedistalairways.Inthedistalairwaythecarbonylgroupofphosgene(ahighlyreactivefreeradical)damages alveolar-capillary membranes, producing non-cardiogenic pulmonaryedema.Itisveryimportanttonotethisprocesscanoccurinadelayedfashion,resultingindelayedonsetofasevereandpotentiallylife-threateninglunginjuryevenafteraninitialpresentationwithoutsignificantsymptoms.

Exposuretolowconcentrationsofphosgenemayproducemildcough,asenseof chest discomfort, and dyspnea. High concentrations may trigger a rapidlydeveloping pulmonary edema with attendant severe cough, dyspnea, laryngos-pasm,andfrothysputum.Onsetofpulmonaryedemawithin2to6hoursispre-dictiveofsevereinjury.

Depending on the intensity of exposure, chest tightness with moderate dys-pneaatrestandprominentexertionaldyspneabecomesevidentwithinthefirst12hoursafterexposure.Thesesymptomsoftenprecedethedevelopmentofpul-monaryedema,whichmaybedelayedmanyhours.

Pulmonaryedemaisthemostseriousclinicalaspectofphosgeneexposureandbeginswithfew,ifany,clinicalsigns.Consequently,earlydiagnosisofpulmonaryedemarequiresthatcarefulattentionbytheHERTtreatmentareastaffbepaidtoanysymptomsofdyspneaorchesttightness.Ifpresent,thesesymptomsrequirefurther evaluation of the victim’s respiratory status, chest x-rays and/or arterialbloodgasesasneeded,andobservation.

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Anhydrous AmmoniaAmmoniaisahighlywater-solublealkalinecolorlessgaswithapungentodor.Itisoftentransportedasapressurizedliquid.Itisusedwidelyinrefrigerationandcoldstoragefacilities,agricultureandindustry.

AmmoniaisasevererespiratoryhazardandeyeirritantwithanIDLHvalueof300ppm.Theodorthresholdofammoniaisapproximately3–5ppm,andithasacharacteristicpungentodor.Highconcentrationsofammoniavaporarevisibleasawhitefog.Ammoniavaporsaregenerallylighterthanairandinopenenvi-ronments they will readily dissipate to the atmosphere, but ammonia can alsoreactwithwaterintheatmospheretoformanammoniumhydroxidevaporthatisheavierthanair.

Uponcontactwithmoistmucosalmembranessuchastheeyesandrespiratorytract, ammonia reacts with water to form a strong alkali (ammonia hydroxide).Thisisastrongalkalinecausticagentthatproducesburnstothecornea,skin,andrespiratorytract.Inhalationcancauseseverecausticinjurytoboththeupperandlowerairways,includingupperairwayobstructionfromedemaandsloughingoftheairwaylining,aswellaspulmonaryedema.

Atapproximately1:37a.m.onJanuary18,2002,a freighttrainderailed31ofits112carsabout½milewestofthecitylimitsofMinot,NorthDakota.Fivetankcarscarryinganhydrousammoniaasaliquefiedcompressedgascatastrophicallyrupturedandavaporplumecoveredthederailmentsiteandsurroundingarea.About 11,600 people lived in the area affected by the vapor plume. As a resultof the accident, one person died, 11 people sustained serious injuries, and 322people,includingthe2traincrewmembers,sustainedminorinjuries.

TrinityHospitalactivateditsdisasterplan,“CodeGreen,”at2:25a.m.,35min-utes after the emergency room was notified of the derailment. Approximately200medicalpersonnelcametothehospitalinresponsetotheCodeGreen.Theadditionalpersonnelsupplementedthe41staffmembersalreadyatthehospital.Staffsecuredthehospitalagainstthehazardousvaporsbyshuttingdownairhan-dlers,settingupaportableair-handlingunitintheemergencyroom,andestab-lishing an alternate emergency room entrance away from the vapor cloud.Theemergencyroomstaffconsultedamaterialsafetydatasheetto findouthowtoeffectivelytreatpersonsexposedtoammonia.Additionally,TrinityHospitalsentarepresentativetotheemergencyoperationscenter.By4:15a.m.,theammoniacloudhaddriftedtoandencompassedthehospital.Throughouttheemergency,TrinityHospitaltreatedapproximately300people.

Methyl Isocyanate (MIC)Methylisocyanateisusedintheproductionofsyntheticrubber,adhesives,pesti-cidesandherbicideintermediates.Itisextremelytoxicbyinhalation,ingestionand

Chapter 2•AssessmentofLikelyMassCasualtyEvents 37

skinabsorption.InhalationofMICcausescough,dizziness,shortnessofbreath,sorethroatandunconsciousness.Itiscorrosivetotheskinandeyes.Short-termexposuresalsoleadtodeathoradverseeffectslikepulmonaryedema(respiratoryinflammation),bronchitis,bronchialpneumoniaandreproductiveeffects.

OnthenightofDecember2,1984,alargequantityofwaterenteredastoragetank containing MIC at the Union Carbide pesticide plant in Bhopal, India inDecember1984.TheplantusedMICasachemicalintermediatetoproducethepesticideCarbaryl.Thistriggeredarunawayreactionresultinginatremendousincreaseoftemperatureandpressureinthetankandthereleaseofapproximately40tonsofMIC,hydrogencyanideandotherreactionproductsintothenightairofBhopal.Thousandswerekilledinthehoursafterthereleaseandthousandslaterdevelopedchroniclungdiseaseandothercomplicationsoftheexposure.MICisusedintheUnitedStatesaswell,makingasimilar,althoughsmallerscaleeventpossible.TheBhopaldisasterisachemicalMCEworthadditionalstudy.

CyanideEachyear,theUnitedStatesproducesapproximatelythreequartersofamilliontons of cyanide. Cyanide is easily obtainable by virtue of its widespread use inindustryandresearchlaboratories.Modestquantitiesareeasilyobtainedviatheinternet.I