EMS Magazine`s Resource Guide: WMD/Terrorism Response

Threat Levels and What They Mean to You: Explained

FEMA's Fire and Emergency Services Preparedness Guide for the Homeland Security Advisory System

Reviewed by Norm Rooker, EMT-P

Emergency responders are daily reminded of the perceived terrorist threat level via the Department of Homeland Security's Advisory System. But what does this actually mean? I know, threat level yellow is worse than threat level blue and threat level red is the worst of all, but what are we supposed to do differently?

FEMA, through the U.S. Fire Administration, has developed a document to aid emergency responders, supervisors, chief officers, managers and planners in interpreting just that. Like all government documents, the Fire and Emergency Services Preparedness Guide for the Homeland Security Advisory System has its share of initials, acronyms and government-speak, but they are kept to a minimum. What it does provide is a concise and readily understandable explanation of all of the five threat levels and what they mean to you and your organization.

The guide begins with a template for the basic level of preparedness that your department, service or local government should have obtained-or be striving to obtain-for dealing with disasters and large emergency situations. It will lead your department to review and update current disaster plans, improve interagency communications, provide for the needs of personnel through family support networks and information systems, and ensure that your agency can provide food and water for troops who suddenly find themselves working on an extended response.

From there, it provides an explanation of each threat level, along with corresponding templates for what your department should be doing in the following areas:

• Information/Planning
• Facility Security
• Personnel
• Operations

As the threat level increases, the template of suggested actions in each of these areas expands to address that level of threat.

FEMA's 11-page guide concludes with a list of related websites that provide additional useful information. Download the guide free of charge from www.usfa.fema.gov/fire-service/cipc/cipc-jobaid.shtm.

Norm Rooker, EMT-P, is a paramedic firefighter for the San Francisco Fire Dept. and has been active in EMS since 1973. He is a heavy-rescue instructor for the California State Fire Marshal's Office, an EMT-T, and a member of his department's surf and cliff rescue teams and technical rescue committee.

UT Southwestern Researchers Receive Federal Grants to Study Biothreats

Researchers at the University of Texas Southwestern Medical Center in Dallas have been awarded $15.1 million in grants from the National Institutes of Health's National Institute of Allergy and Infectious Diseases to study anthrax, ricin, plague, tularemia and Lassa fever-all pathogens that can be used as biological weapons. The largest grant is a 4½-year, $8.7 million award to study tularemia, a deadly infection caused by the bacterium Francisella tularensis, which, according to the chairman of microbiology at UT Southwestern, is easier to use as a weapon than anthrax. Approximately 50–100 incidences of tularemia occur naturally in the U.S. each year, most often in farmers, veterinarians and hunters. It can be transmitted through a bite from an infected animal, such as a mouse, squirrel or rabbit, or by direct contact with the animal's tissues or fluids.

Tularemia is classified by the government as a Category A biothreat, which is the most dangerous classification. Aerosol dissemination of the bacteria in a populated area would result in a sudden onset of a bacterial infection in a large number of people within 3–5 days.

Ricin, classified as a Category B biothreat, can be administered in food or water, or sprayed as an aerosol. A small dose can produce flu-like symptoms and result in death within a few days. Researchers at UT Southwestern's Cancer Immunobiology Center received a 3½-year, $1.5 million grant to lead a team in developing a vaccine for ricin and for initiating clinical trials. An experimental vaccine has been developed, and the team hopes to begin field trials of the intramuscular vaccine this spring.

Anthrax, a Category A biothreat, is No. 1 on the nation's list of potential bioterrorism threats. Researchers will use a $1.5 million grant to engineer antibodies targeting the disease.

HHS Awards Grant for Bioterrorism Training

Thomas Jefferson University Hospital in Philadelphia, PA, is one of 19 U.S. medical centers to receive a grant from the U.S. Dept. of Health and Human Services to provide bioterrorism training and education for the healthcare workforce. Jefferson was awarded $968,102 for each of two years to support its Recognition to Recovery (R2R) continuing education program, which will focus on training healthcare workers to achieve the optimal response to patients injured during an act of terrorism.

Working with the emergency response and public health systems, the R2R project expects to develop a two-hour basic core course that will be applicable to all healthcare professionals. The course will be CME-eligible and will include an overview of initial response, emergency department management (including decontamination and incident command) and hospital management of victims of nuclear, chemical and biological agents. Much of the course content will be available online through the Pennsylvania Department of Health's Learning Management System website. It will also serve as the basis for developing a "Train the Trainer" curriculum for the R2R program to expand the training to as many professionals as possible.

In addition to the basic course, there will be courses tailored to each of the medical specialties, along with quick reference guides, downloadable fact sheets and links to Web-based information. The onsite basic core curriculum and course content for each discipline will be piloted at Jefferson Hospital and Albert Einstein Medical Center during the first year with residents, faculty, EMS and emergency medical staff and other healthcare professionals.

A key component of the curriculum will include disaster drills to prepare learners to participate in a multidisciplinary terrorist response and serve as a method to develop team collaboration during terrorist events.

Jane's Offers Prehospital Disaster Handbook

It's a dirty-nuke attack-quick, what do you do? No, wait-it's a biological outbreak. What does that mean for you? Hold on-now it looks like an intentional release. How does that change things?

By now, some of you may have reached for several different resources. Radiological requirements here, infectious-disease protocols there, bioterror considerations over yonder. Useful one and all, but inconvenient when seconds count. Who can waste time juggling references in an emerging disaster?

For many, having a single, convenient wide-ranging resource for a variety of disaster situations would be preferable. To meet that need, Jane's Information Group-a leading publisher of defense, transport and security news, information and analysis-offers Jane's Mass Casualty Handbook:?Pre-Hospital, a comprehensive guidebook to preparing for, responding to and recovering from disasters both natural and manmade.

"After almost 30 years in EMS, I didn't feel there was really a compendium of classical, tried-and-true information in this area that had been formatted into a user-friendly design," says the book's editor and lead author, Craig DeAtley, PA-C, a former paramedic and a leading expert on disaster preparedness. "Certainly, there are some excellent books on disaster, but that's a key difference:?Those are books; this is a handbook. We wanted to provide down-to-earth suggestions for planning and response to many of the most common types of disaster situations we can expect to see."

The book-a companion to Jane's Mass Casualty Handbook:?Hospital, published earlier in 2003-identifies planning issues and discusses common disaster scenarios, outlining applicable action steps and response considerations. Topics covered include the full range of CBRNE threats; on-scene procedures; incident command; PPE; decontamination procedures; and treating casualties.

"We try to give some unique planning insights, as well as some response principles to keep in mind," says DeAtley.

For more information or to order Jane's Mass Casualty Handbook:?Pre-Hospital, visit https://catalog.janes.com/catalog/public/index.cfm?fuseaction=home.ProductInfoBrief&product_id=9270.

The victims had been exposed to a nerve agent and needed decon, stat. A hazmat team was on-scene, ready to act. But it did not-it could not. Its responders watched and waited while the exposed died gruesome, painful deaths.

The holdup in this recent terrorism-response drill was that the hazmat team had no receptacles to collect the water it would use for decontaminating victims. With state and federal officials watching, responders couldn't let the runoff contaminate the environment-so they were forced to wait for additional equipment to arrive. Meanwhile, "victims" perished needlessly.

Fortunately, this was only a drill, but the issue it highlighted is real. Faced with the choice, do you risk harming the environment to save lives, or do you save lives and risk not only the environment, but legal consequences as well?

The correct answer is B. If you have no other options, do the decon and don't sweat it-you're covered.

Section 107(d) of the pertinent Comprehensive Environmental Response, Compensation and Liability Act?(CERCLA) says, "No person shall be liable…for costs or damages as a result of actions taken or omitted in the course of rendering care, assistance or advice in accordance with the National Contingency Plan…with respect to an incident creating a danger to public health or welfare or the environment as a result of any releases of a hazardous substance."

What this means, according to a clarification issued by the Environmental Protection Agency, is that the "EPA?will not pursue enforcement actions against state and local responders for the environmental consequences of necessary and appropriate emergency response actions."

This so-called "good Samaritan" provision does not preclude liability for negligent releases, and it requires good-faith efforts to avoid or mitigate environmental consequences-you can't just wash decon runoff down a storm drain because you don't want to deal with it. But it does shield providers-and, in a subsequent section, state and local governments as well-for doing what they have to do to save lives.

This doesn't mean you won't get sued. CERCLA protects responders doing their jobs from federal prosecution, but depending on applicable state tort laws, individuals or businesses may still seek compensation for damage or losses. Your degree of immunity/liability may vary depending on your location. The federal on-scene coordinator who liaisons with local responders at such incidents can assist you in determining which environmental regulations apply under the circumstances. Involving this individual in any decision-making process is important to reducing any potential liability. Planning for dealing with issues like runoff is also key. Not having the equipment and plans in place to do so may in itself constitute negligence.

For more on this subject, visit www.epa.gov/ceppo.

A One-of-a-Kind Training Center

The Noble Training Center in Ft. McClellan, AL, operated by the Department of Homeland Security and the Federal Emergency Management Agency (FEMA), is unique in that it is the only hospital facility in the United States devoted to medical training for healthcare professionals in disaster preparedness and response.

"We were started by the U.S. Public Health Service in 1999, when Congress directed the Dept. of Health and Human Services to take over the Noble Army Community Hospital at Ft. McClellan and convert it into a national medical WMD training center for hospital personnel," says program manager John Hoyle. "We use the building for two basic purposes. One is as a mock hospital training environment, where we can carry out all kinds of drills and exercises that you could not do in a functioning hospital." Drills, says Hoyle, are designed to simulate the stress of a real disaster, which, unlike most hospital disaster drills that last for a few hours, can go on for days.

"The second purpose of the building is to do some beta testing of new innovations for the medical sector of homeland defense," says Hoyle. "To that end, we have built two well-designed mass casualty decontamination units, one for ambulatory patients and one for nonambulatory patients. With that, we stress the dual use of facilities. For example, the nonambulatory decon is set up in an ambulance garage. Day to day, it can be used as a garage, but it can be quickly converted for mass casualty decontamination."

The program's aim is to bring in hospital teams, consisting of a hospital executive, a nurse executive, an emergency physician, an ED manager and a hospital chief facilities officer. In addition, hospitals are encouraged to include the EMS administrator and a public health leader from their community to round out the team.

Classes run from Monday afternoon to around 1 p.m. on Friday, with no cost for instruction, transportation or housing. Instructors from a wide range of specialties come in from all over the country.

"The course is a mix of didactics and drills," says Hoyle. "Each of the three principal exercises is graded and becomes more complex as they progress. We have a fine didactic curriculum to teach the hospital emergency incident command system (HEICS) and how unified command works, so a hospital is not just functioning in isolation, but rather is part of a community-wide incident management system. Another thing we do is all-hazards scenarios in chemical, biological and radiation training. We do explosions and fires, so people can see the vast numbers of wounding mechanisms and how a victim, particularly of terrorism, can have more than one type of injury."

Although there is no certification, it is intended to be a "train-the-trainer" program, says Hoyle.

"That's why it's important for hospitals to send us the composition of team that is specified so, when they go home, they can take what they learn to make significant improvements in their own hospital, EMS and public health preparedness plans."

The center is currently teaching an integrated emergency management course for CDC personnel, and will soon offer a special integrated emergency management course adapted for Metropolitan Medical Response System cities. Although there is a waiting list, it's not a long one, says Hoyle, who adds that class sizes are usually around 60–65 people, or approximately 8–10 teams.

For more information, visit www.training.fema.gov/emiweb/NTC.

Website Roundup

This month, EMS Magazine introduces a new department that profiles websites and online destinations that emergency responders might find worthwhile to check out. We'll offer a brief rundown of what can be found on the site, but no guarantees about its veracity or security.

Our debut website of interest comes to us from Grant Russell, emergency communications specialist at the Kennedy Space Center in Orlando, FL, who writes, "This is a very detailed website; good reading/education, etc."

www.twotigersonline.com/resources.html

Thank you, Mr. Russell; detailed is right.

Billing itself as: "A leading source for the tools and sensors used during radiation emergencies," the website for Two Tigers Radiological is chock full of state-of-the-art equipment and supplies, but it's the Knowledgebase that impresses. The above URL takes you to 17 printed pages, titled National Homeland Security Knowledge­base, where you can link to scores of federal agencies and public and private resources that concern themselves with national safety and emergency intervention, including:

• Nuclear/radiological emergencies, biological emergencies, chemical emergencies, hazardous devices, bombs and explosive ordnance emergencies and natural disasters
• Federal homeland security agencies and organizations (from the White House to the National Library of Medicine)
• State homeland security/emergency management organizations (state by state)
• Homeland Security resources (from the Kennedy School of Government to the Heritage Foundation, these direct you to political and think-tank positions on terrorism, strategies for defense, and readiness)
• Worldwide resources, organizations, societies, labs and facilities
• Earthquake and weather maps and resources.

There are also explicit tips for preparedness; a sidebar feature called Terrorism News, updated every 15 minutes; and "Instant Answers" for: When you need to know where the wind is blowing; when the ground is shaking; when you are on the run; how to build a log cabin; when you want to store food; and pet safety. This is truly a one-stop shop for "everything you ever wanted to know about homeland security but were afraid to ask." Which leads me to their disclaimer that might bear mention and a "ditto" from EMS: "We specifically disclaim any responsibility for the recommendations or fitness of any recommendation for any particular purpose and shall in no event be liable for any loss of profit, life, or any other damage, including but not limited to special, incidental, consequential, or other damages."

Surf safely.

If you know of a website you think our readers should have in their favorites folder, send a link and a few words about why you like it to emseditor@aol.com.

Fumbling, Flipping Phased Out by New Software in Mississippi

You arrive to find several patients, all with runny noses, chest tightness and difficulty breathing. What's at work here? A chemical exposure, quite possibly, but this is no time to fumble through references to figure out what it might be, how to treat these patients and how to protect yourself.

"You can find all that information in a paper-based system," says Paul LeBlanc, assistant director of Mississippi's DeSoto County EMS, "but who has the time to look when you've got sick people around you?"

In DeSoto County-part of the greater Memphis, TN, metropolitan area-flipping and fumbling are a thing of the past. The service has implemented a pilot program using ThreatScreen, a software program from Annapolis, MD-based Realinterface that quickly matches symptoms like those above to agents that might have caused them.

Even if providers don't immediately suspect a chemical cause-say there's a single patient with only general signs and symptoms-as they enter the patient's data into the Palms they all carry, via yes/no options and simple decision trees, ThreatScreen automatically scans the data and initiates WMD screening if enough symptoms match. It doesn't stop there. Once a likely cause is identified, crews can call up their local protocols for dealing with it, including PPE and decon procedures. ThreatScreen also allows the forwarding of patient data to higher authorities, such as regional or state health departments, thus enabling widespread surveillance.

ThreatScreen's surveillance capability is especially important in this day and age. If a biological agent is released, the infected will subsequently present at different times and places. Identifying what's going on as quickly as possible is vital to an effective response.

"If one of our crews picks up a patient and determines it's smallpox, it'll tell them ‘Go to Hospital X,' " says LeBlanc. "That way we don't end up infecting and shutting down all our regional hospitals with one smallpox victim apiece. It's as close as possible to a real-time reporting of events, and as they roll it out statewide, they'll be able to gather information from all across the state."

ThreatScreen can run on PDAs or PCs. DeSoto County already used Palms for its run reports, making implementation easy. The software and run reports currently operate separately, but the service expects to link them so that reports are automatically scanned without ThreatScreen having to be used independently.

ThreatScreen's usefulness goes beyond WMD. Also in its library are standard infectious diseases, and as new threats like SARS or avian flu emerge, doctors at Realinterface update the library to include them.

"They're out watching for those types of events, and with an emerging infectious disease, we get the protocols put in, at least from the national level," says Realinterface's Jim Storey. "If something happens in California, the next time somebody from Mississippi syncs up, it's there."

For more on ThreatScreen, visit www.realinterface.com.

Hazmat for Healthcare: Managing the Contaminated in a Hospital Environment

Hospitals can be hazardous places. Even as staff tend and mend the injured and ill, they face an array of threats from within and without. Internal chemical accidents are always possible, and anything that walks into the emergency department has the potential to impact operations.

Managing contaminated patients thus becomes of critical importance for hospitals. Yet most hazardous-materials training is geared for fire or other emergency responders, not for the hospital environment.

Developed in 2000 by a wide-ranging consortium of emergency preparedness professionals and healthcare heavyweights in California, Hazmat for Healthcare is a solution for hospitals that may benefit prehospital providers as well.

"We developed this program because we couldn't find anyone else's to steal," jokes Paul Penn, who was involved in the effort from its outset and now offers the training through a company called EnMagine. "Our original intent was to gather existing materials into something useful for hospitals in the Sacramento region. Unfortunately, we didn't find anything that actually met our needs. The vast majority of material out there was fire and non-healthcare-based-fine in a prehospital setting, but not applicable to us. So we had to develop a whole new program."

The group first produced a document, Management of the Contaminated Patient, containing guidelines for staff safety when dealing with victims of toxic exposures. From this, it broadened its effort to address equipment and training needs as well. The comprehensive final product, modular and fully compatible with the Hospital Emergency Incident Command System (HEICS), was unveiled in early 2001, and has now been implemented throughout the greater Sacramento area. In addition, it has been made available online and taught all around the U.S.

"There's been an incredible amount of interest," says Penn. "Part of it is that it answered a need: That the material out there was not hospital-specific, or that existing material was so proprietary that you had to pay thousands of dollars for it."

That's not the case with Hazmat for Healthcare, which is copyrighted but not proprietary. The program, including a train-the-trainer component, is offered to emergency-services users at no charge, providing they do not charge those whom they subsequently train. For organizations not possessing the expertise in-house, EnMagine provides the training on a fee-for-service basis.

Management of the contaminated patient remains a central aspect of the program. Hazmat for Healthcare promotes a concept of directed self-decon for those who can do it.

"Most of the hazmat exposures you're going to see in a hospital are limited numbers of people who are ambulatory and can follow directions," says Penn. "In those cases, rather than you performing the decontamination, you can actually have the victims decontaminate themselves, using soap and water, without having physical contact with them."

This allows decon to be guided by staff trained at the Awareness level, rather than the Operations level (though the latter is still required for hands-on decon of the non-ambulatory, those who can't follow directions, mass decon events, etc.).

Among those taking note are prehospital providers. With slight modifications, Hazmat for Healthcare can be offered to fire and EMS audiences.

"We talk about those things they may encounter in a prehospital setting," says Penn. "It requires very little modification-no matter where you are, the contamination issues are essentially the same. For an EMS?audience, we'd probably deal less with internal spill events, and more with recognizing what's occurring-what people in a prehospital-care environment need to be aware of to protect themselves. Medics who have attended Hazmat for Healthcare appreciate the emphasis on responder safety and care of the patients."

For more information, see www.hazmatforhealthcare.org.

ASTM Forms Standards Committee on Homeland Security Applications

The American Society for Testing and Materials (ASTM) has developed Committee E54 on Homeland Security Applications to identify and develop performance standards for first responder equipment, with participation from a wide variety of stakeholders, including representatives from the Department of Homeland Security, U.S. Environmental Protection Agency, U.S. Secret Service, as well as first responders, security product manufacturers, trade associations and academia. While there is no deadline for the documents, ASTM is committed to make them available as quickly as possible, says Pat Picariello, ASTM's director of Developmental Operations.

"Our process can develop a standard, without impediment, in as little as 40 days," he says. "We have heard repeatedly from DHS and segments of this industry that standards are needed yesterday. It's our hope that this activity evolves as quickly as possible, because the need here is pretty significant."

Equipment is a top priority, says Picariello.

"From DHS's perspective, equipment is probably the biggest and most obvious vacuum right now. A lot of products are being manufactured, designed and marketed to the first response community, and they may or may not be able to do what they claim. The problem is there's no set of performance standards that can be used to validate that, and that's important. When you're walking into an environment with apparatus that's supposed to detect something, you want to make sure it can do what it purports."

The scope of Committee E54 is much broader than equipment, however. There are currently seven subcommittees focusing on areas like decontamination, emergency preparedness training and procedures, personal protective equipment, security systems, and building and infrastructure protection.

"Every stakeholder, be they product manufacturer, regulator, user or anyone who is concerned about this and can provide feedback, has the opportunity to participate in ASTM's process," says Picariello. "We are entirely open to anyone with a demonstrated interest, and would like as much feedback as possible from as wide a variety of folks as we can possibly find. They can find out more information about the committee or ASTM, or, if they're interested in participating, they can fill out an application on the ASTM website at www.astm.org."

Interoperability Now!

The Washington, DC-based ComCARE Alliance is a nonprofit national coalition of more than 90 organizations representing a broad spectrum of healthcare providers and other groups. ComCARE, or Communica-tions for Coordinated Assistance and Re-sponse to Emergencies, encourages development and deployment of communications and information technologies that will enhance America's emergency capabilities.

For the past two years, ComCARE has worked with public safety leaders in Virginia to demonstrate and deploy a modern interoperable emergency communications system. In October 2003, they collaborated with the Virginia Hospital and Healthcare Association (VHHA) to demonstrate the E-Safety Network during a statewide bioterrorism drill, sponsored by the Virginia Dept. of Health. The drill involved hospitals across the state responding to the release of pneumonic plague. After many people arrived at hospitals complaining of flu and pneumonia-like symptoms, the Dept. of Health announced the "release of pneumonic plague by terrorists" and told hospitals how many patients they had. Hospital participants used the E-Safety Network to communicate and coordinate their efforts. ED status and bed capacities were recorded and the data exported into an integrated hospital-capacity information page for viewing by state officials.

While the hospitals' healthcare providers responded to the influx of "patients," outside emergency responders simulated additional events like a hazmat incident and traffic congestion from parties fleeing Washington, DC. Local hospitals sent CAP messages to update dispatchers on their hospital status, highlighting the direct connection between all of the appropriate responders in an emergency.

Using Emergency Services Integrators LLC (ESI) WebEOC data messaging capability rather than telephone calls, hospitals could send messages to one or multiple sites within their region in real time. In addition, the regional coordinating hospitals were connected to each other and the state health department EOC in a private messaging group. WebEOC also allowed participating hospitals to input data on available staff, medications, ventilators and other resources relevant to the bioterrorist attack through quickly created forms, which could then be shared regionally or statewide.

For communications with parties not on the VHHA system, common alerting protocol messaging was available through the WebEOC portal, using ComCARE's Emergency Provider Access Directory as the map-based and incident type router. When geography was important to a message, incidents were displayed on the emergency incident website from GeoDecisions. Key personnel were alerted through mobileFoundations' technology to cell phones, pagers, personal PCs, etc. A wireless data system from Optimus was able to extend the information directly to mobile ambulances and allow them to update it.

The combination of technologies provided a broad picture of the mock attack and kept participants feeling informed. The drill measured the abilities of hospitals to coordinate and share vital information within their own organizations, the region, and state hospital and health agencies.

ComCARE's vision is to increase communication among agencies to provide more effective emergency preparedness and response, in part by enabling modern, interoperable data communications that allow emergency responders to make quick and accurate decisions, reduce response time and encourage the timely distribution of resources by providing responders with instant interoperability.

The drills also demonstrated the E-Safety Network's value in providing low-cost, highly realistic training for emergency responders. With only a laptop computer, an ISP account and a broadband connection, agencies were able to realistically participate.

The shared vision of the ComCARE Alliance and its members is of an integrated emergency communications and information system linking the public to emergency agencies and agencies to each other in a seamless, secure network. They believe the E-Safety Network will save lives, reduce the impact of serious injuries, enhance homeland security, conserve public safety and hospital resources and improve transportation efficiency.

A full account of the October drill, along with a history and list of participants, can be found at: https://www.comcare.org/projects/states/va/ExecSum.pdf. For more information on other ComCARE activities, e-mail info@comcare.org.