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EMS Responce to Terrorism

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Emily Miller
Emily Miller

Independent research project created for Nashoba Regional High School's EMT Cadet Program, run by Bolton Ambulance Squad and Quality EMS educators.

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EMS Response to Terrorism "I think about the job done yesterday, and tip my hat to the responders, pray for the victims, and thank whatever forces led me to this calling." - Michael Morse, rescue captain with the Providence Fire Department
Terrorism The unlawful use of force or violence against persons or property to intimidate or coerce a government, the civilian population or any segments thereof, in furtherance of political or social objectives" Types o Domestic - activities are directed at a government or population, without foreign direction Environmental terrorists, Survivalists, Militias, Racial-hate groups, Extreme political or religious groups o International -"activities are foreign-based and/or directed by countries or groups outside the target country or whose activities cross national borders.
First Responders Role EMS is usually principle target of terrorist attacks o keep safety top priority! Isolation o Incident command and law enforcement's job is to isolate hazards and organize evacuation Notification- potential crime scene o follow protocols, incident communications may request additional specialized agencies Identification of threat (containers, or specific indicators) protect critical assets! Gross decontamination (do it)
First Responder Role Count. Scene Size-up o signs of HAZMAT o Unconscious o SLUDGEM signs (explained later) o skin irritants and symptoms o difficulty breathing Situational Awareness o mass casualties/fatalities with little or no trauma o responder casualties o dead animals and plants Don't Rush In! (clear scene, PPE, secondary explosive devices, search all patients)
Identify Threat Posed by Event - OTTO potential act of terrorism is crime scene OTTO o Occupancy (location) - Symbolic targets, public/assembly areas, businesses, infrastructure o Type of event -scene involves guns, explosions, mass casualty with no trauma o Timing of event - holidays, anniversary, public gatherings, busy times of day o On-scene warning signs -unexplained patterns, signs, symptoms, and containers
Take Home Message is you remember nothing else Time/Distance/Shielding o Time - minimize exposure, perform quickly o Distance - maximize, distances given in Emergency Response Guidebook o Shielding - Emergency Response Guidebook for specific shielding, appropriate PPE, breathing gear, hide behind cars, buildings, wear HAZMAT suits, get vaccinations
Weapons of Mass Destruction CBRNE o Chemical o Biological o Radiological o Nuclear o Explosive o Criminal activities Harms Posed by Threat TRACEM-P o Thermal o Radiological o Asphyxiation o Chemical o Etiological (disease) o Mechanical o Psychological
Chemical Incidents TRACEM-P usually exposed through inhalation o heat, explosives, and sprayers can aerosolize materials o could be ingestion, injection, absorption Self-Protection o respiratory gear HAZMAT clothing o decontaminate pts Volatility - choose chemicals w/ low boiling point and high vapor pressure to evaporate quickly o greater airborne release potential Agents can be gaseous, liquid, or solid
Classes of Chemical Agents Choking agents o e.g. chlorine o causes - upper or lower-respiratory irritation, lacrimation, chest pain, dyspnea, coughing, laryngeal edema, pulmonary damage/ edema Cyanides o Prevent use of oxygen in cells o highly volatile, rapidly acting chemical agents. o e.g. hydrogen cyanide (AC) o cause - air hunger, hyperpnea, apnea, seizures, coma, and death Vesicating (blister) agents o e.g. mustard gas, sulfur mustard (HD), nitrogen mustard (HN), agent T o may be toxic to the lungs, eyes, and mucous membranes o lesions are usually skin, but can be respiratory, ocular, and GI o can also cause - cough, bloody sputum, and dyspnea o symptoms may not occur for several hours
Classes of Chemical Agents Count. Nerve agents o Inhibit neurotransmission o signs- SLUDGEM! Salivation Lacrimation Urination Defecation GI Upset Emesis (vomit) Miosis (small pupils) o can also cause airway problems o Onset varies from 1 minute to a few hours (skin vs air) lacrimators / irritating agents o e.g. (tear gases) o cause - nasal/ocular discharge, photophobia, burning sensations o may cause -chest tightness tightness, shortness of breath, and malaise Incapacitating agents o delayed-onset (1-4 h) o cause tachycardia, dizziness, vomiting, blurred vision, stupor, confusion, and random activity o can make person docile, belligerent, stuporous, or confused (seem intoxicated)
Biological Incidents Caused by o bacteria, viruses, and/or toxins focused emergency or public health emergency? Role of EMS is primarily supportive o material can replicate itself Four major routes o absorption, ingestion, injection, inhalation Exposed or Contaminated? TRACEM Self-Protection o PPE, respiratory protection o Get as much info as possible and prioritize
Examples of Biological Weapons Anthrax (Bacillus anthracis) easy to access, and durable, small number of anthrax spores causes the inhalational form 1- to 3-day incubation period, hard to diagnose in early stages and difficult to treat once clinical signs are apparent signs/ symptoms o necrotic lesions that spontaneously heal o fever o dyspnea (shortness of breath) o necrotizing hemorrhagic mediastinitis (bloody death of tissue) o hypotension Death within 24-36 hours up to 7 days Brucellosis (Brucella) bacteria less commonly fatal signs/ symptoms o draining lesions o fever o malaise o osteomyelitis (bone infection) o genitourinary (genital and urinary) infections o endocarditis (inner heart lining inflammation) - cause of death
Examples of Biological Weapons Count. Encephalitis viruses mosquitoes are a vector Signs and Symptoms o fever o headache o confusion and obtundation (dulled senses) o dysphasia (impaired speech) o seizures and paresis vaccine for Venezuelan equine encephalitis (VEE) is available Smallpox virus vaccine no longer is produced Aerosol exposure signs and symptoms o viremia (viruses in blood) o malaise o fever o headache and/or delirium o prolonged rash Allergens mite/insect particles, epithelium, hair, urine, feces, and powdered enzymes could cause respiratory symptoms, conjunctivitis (pink eye), and/or dermatitis (skin inflamation) Others Clostridium botulinum Yersinia pestis (plague)
Radiological Effects of radiation on bone, GI, CNS TRACEM-P Self-Protection o Time, distance, shielding o Radiologic detecting equipment, assume dissemination radiological dispersion o practical and difficult to detect o symptoms are delayed o treatable if early detection Devices o Military nuclear device o Improvised o Radiological dispersal device (dirty bomb) o Sabotage
Incendiary variety of devices o may involve attacks on a fixed target or group of people o assume designed to disperse bio, chem, radiologic materials TRACEM-P Self-Protection o preblast vs postblast Blast injury patterns o Lung injury - bradycardia, apnea, and hypotension o Ear injury - tympanic membrane (loss of hearing, blood, ringing) o Abdominal injury o Brain injury - concussion or mild traumatic brain injury (MTBI)
Boston Marathon Bombings responders performed selfless and heroic acts of care and compassion, situation was special due to large amount of EMS who were on hand for the marathon itself and were on the scene within seconds, race tents were utilized as cold zone o Doctors were "pulling ball bearings out of people in the emergency room...a terrifying scene of shattered glass, bloodstained pavements and severed limbs." -terrorism expert o "Somebody's leg flew by my head. I gave my belt to stop the blood" -John Ross o "They just started bringing people in with no limbs" -Tim Davey o "They just kept filling up with more and more casualties...Most everybody was conscious.They were very dazed." -Lisa Davey o "This is something I've never seen in my 25 years here ... this amount of carnage in the civilian population." -Alisdair Conn, chief of emergency services at Massachusetts General Hospital
CNN Report on First Responders
We Can't Always Help unexploded bombs were rampant Adrian judged scene was not secure The conflict between personal priorities and the call to duty can be significant o sometimes we can become part of the problem not aid solution "They were disoriented and dehydrated from the race, and really couldn't talk much...I couldn't do very much for them, other than stay with them until friends arrived to help them home." o -EMT Adrian Will-Orrego, junior at Northeastern
Adam Lane We had just left the area a minute before the explosion...We could feel the concussive energy of the primary blast wave At first we didn't know what it was...We saw a lot of people run by. It seemed that it was almost instantaneous that medical responders were all over the place, tending to the wounded I made the right decision to stay with my friends and go help other runners who were not injured but were still shocked and exhausted by what happened You realize after something like this, there is a lot that is just beyond your control...Had we been delayed a few minutes, things could had been very different o -Adam Lane EMT, PA student studying at the Massachusetts College of Pharmacy and Health Sciences
Marathon: IEDs Improvised Explosive Device: o homemade bomb or destructive device created to destroy, incapacitate, harass, or distract wide variety of forms can be thrown, placed, or concealed composed of package o e.g. vehicle, a package, cans, backpacks, vests etc. initiating system o set off the main charge to make it detonate o e.g. cell phone, toy RC, etc. main charge o almost always includes a blasting cap and batteries o any type of battery can be used (e.g. 9- volt, AA, car batteries, etc.)
IED Deployment Triggered Over time: allow enemy to escape or to target victims On command: choose the optimal moment, used against mobile targets with established pattern o include wires or radio controlled devices Victim o switches include pull or trip, pressure, pressure release, movement-sensitive, light- sensitive, proximity Deployment Techniques disguised in a variety of things Multiple IEDs can be linked together with detonation cord o charges detonate simultaneously often secondary devices and multiple explosions to increase victims o scene safety! gunfire, small bombs, and other distraction tactics can bait victims into the kill zone of a second IED Multiple locations are common with IED bombers so command officers must be mindful of their resources
Specific IEDs VBIED: parked vehicle in a high traffic area VBIEDS: suicide driver VBIED o hard to detect and stop o bomber -mobile, able to choose time, place, and victims Suicide Bombers Personal Borne IEDS (PBIED) attack with an explosive vest, belt, or baggage attached to person o commonly hold up to 12 lbs of explosives (can be as high as 45) and incorporate fragment materials into the design o potential attack attempting to circumvent security checkpoint or gate wearing too much clothing for the weather suspicious bulges in clothing
Works Cited EMS1 Staff. 3 dead, dozens injured after Boston Marathon explosions. EMS1. N.p., 15 Apr. 2013. Web. 19 Apr. 2013. <http://www.ems1.com/mass-casualty-incidents-mci/articles/1432242-2-dead- dozens-injured-after-Boston-Marathon-explosions/>. French, Glenn. Boston bombings: IED recognition for patrol officers. PoliceOne. N.p., 17 Apr. 2013. Web. 19 Apr. 2013. <http://www.policeone.com/terrorism/articles/6199597-Boston-bombings-IED- recognition-for-patrol-officers/>. Hsieh, Art. Boston bombings: EMT stories from the scene. EMT1. N.p., 18 Apr. 2013. Web. 19 Apr. 2013. <http://www.ems1.com/columnists/art-hsieh/articles/1434117-Boston-bombings-EMT-stories-from- the-scene/>.
Works Cited Count. Kaye, Randi. CNN News Report. Youtube. N.p., 17 Apr. 2013. Web. 21 Apr. 2013. <http://www.youtube.com/watch?v=fRD90hRb5gQ>. Limmer, Daniel, et al. "EMS Responce to Terrorism." Emergency Care. Ed. Edward T. Dickinson. 12th ed. Upper Saddle River: Pearson Education, 2012. 1063-97. Print. Morse, Michael. The Boston bombings: EMS efforts made me proud, humble. EMT1. N.p., 16 Apr. 2013. Web. 19 Apr. 2013. <http://www.ems1.com/columnists/michael- morse/articles/1432737-The-Boston-bombings-EMS-efforts-made-me-proud-humble/>. Stephens, Everett. EMS and Terrorism. Medscape. N.p., 24 July 2008. Web. 19 Apr. 2013. <http://emedicine.medscape.com/article/765132-overview#showall>.

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EMS Responce to Terrorism

  • 1. EMS Response to Terrorism "I think about the job done yesterday, and tip my hat to the responders, pray for the victims, and thank whatever forces led me to this calling." - Michael Morse, rescue captain with the Providence Fire Department
  • 2. Terrorism The unlawful use of force or violence against persons or property to intimidate or coerce a government, the civilian population or any segments thereof, in furtherance of political or social objectives" Types o Domestic - activities are directed at a government or population, without foreign direction Environmental terrorists, Survivalists, Militias, Racial-hate groups, Extreme political or religious groups o International -"activities are foreign-based and/or directed by countries or groups outside the target country or whose activities cross national borders.
  • 3. First Responders Role EMS is usually principle target of terrorist attacks o keep safety top priority! Isolation o Incident command and law enforcement's job is to isolate hazards and organize evacuation Notification- potential crime scene o follow protocols, incident communications may request additional specialized agencies Identification of threat (containers, or specific indicators) protect critical assets! Gross decontamination (do it)
  • 4. First Responder Role Count. Scene Size-up o signs of HAZMAT o Unconscious o SLUDGEM signs (explained later) o skin irritants and symptoms o difficulty breathing Situational Awareness o mass casualties/fatalities with little or no trauma o responder casualties o dead animals and plants Don't Rush In! (clear scene, PPE, secondary explosive devices, search all patients)
  • 5. Identify Threat Posed by Event - OTTO potential act of terrorism is crime scene OTTO o Occupancy (location) - Symbolic targets, public/assembly areas, businesses, infrastructure o Type of event -scene involves guns, explosions, mass casualty with no trauma o Timing of event - holidays, anniversary, public gatherings, busy times of day o On-scene warning signs -unexplained patterns, signs, symptoms, and containers
  • 6. Take Home Message is you remember nothing else Time/Distance/Shielding o Time - minimize exposure, perform quickly o Distance - maximize, distances given in Emergency Response Guidebook o Shielding - Emergency Response Guidebook for specific shielding, appropriate PPE, breathing gear, hide behind cars, buildings, wear HAZMAT suits, get vaccinations
  • 7. Weapons of Mass Destruction CBRNE o Chemical o Biological o Radiological o Nuclear o Explosive o Criminal activities Harms Posed by Threat TRACEM-P o Thermal o Radiological o Asphyxiation o Chemical o Etiological (disease) o Mechanical o Psychological
  • 8. Chemical Incidents TRACEM-P usually exposed through inhalation o heat, explosives, and sprayers can aerosolize materials o could be ingestion, injection, absorption Self-Protection o respiratory gear HAZMAT clothing o decontaminate pts Volatility - choose chemicals w/ low boiling point and high vapor pressure to evaporate quickly o greater airborne release potential Agents can be gaseous, liquid, or solid
  • 9. Classes of Chemical Agents Choking agents o e.g. chlorine o causes - upper or lower-respiratory irritation, lacrimation, chest pain, dyspnea, coughing, laryngeal edema, pulmonary damage/ edema Cyanides o Prevent use of oxygen in cells o highly volatile, rapidly acting chemical agents. o e.g. hydrogen cyanide (AC) o cause - air hunger, hyperpnea, apnea, seizures, coma, and death Vesicating (blister) agents o e.g. mustard gas, sulfur mustard (HD), nitrogen mustard (HN), agent T o may be toxic to the lungs, eyes, and mucous membranes o lesions are usually skin, but can be respiratory, ocular, and GI o can also cause - cough, bloody sputum, and dyspnea o symptoms may not occur for several hours
  • 10. Classes of Chemical Agents Count. Nerve agents o Inhibit neurotransmission o signs- SLUDGEM! Salivation Lacrimation Urination Defecation GI Upset Emesis (vomit) Miosis (small pupils) o can also cause airway problems o Onset varies from 1 minute to a few hours (skin vs air) lacrimators / irritating agents o e.g. (tear gases) o cause - nasal/ocular discharge, photophobia, burning sensations o may cause -chest tightness tightness, shortness of breath, and malaise Incapacitating agents o delayed-onset (1-4 h) o cause tachycardia, dizziness, vomiting, blurred vision, stupor, confusion, and random activity o can make person docile, belligerent, stuporous, or confused (seem intoxicated)
  • 11. Biological Incidents Caused by o bacteria, viruses, and/or toxins focused emergency or public health emergency? Role of EMS is primarily supportive o material can replicate itself Four major routes o absorption, ingestion, injection, inhalation Exposed or Contaminated? TRACEM Self-Protection o PPE, respiratory protection o Get as much info as possible and prioritize
  • 12. Examples of Biological Weapons Anthrax (Bacillus anthracis) easy to access, and durable, small number of anthrax spores causes the inhalational form 1- to 3-day incubation period, hard to diagnose in early stages and difficult to treat once clinical signs are apparent signs/ symptoms o necrotic lesions that spontaneously heal o fever o dyspnea (shortness of breath) o necrotizing hemorrhagic mediastinitis (bloody death of tissue) o hypotension Death within 24-36 hours up to 7 days Brucellosis (Brucella) bacteria less commonly fatal signs/ symptoms o draining lesions o fever o malaise o osteomyelitis (bone infection) o genitourinary (genital and urinary) infections o endocarditis (inner heart lining inflammation) - cause of death
  • 13. Examples of Biological Weapons Count. Encephalitis viruses mosquitoes are a vector Signs and Symptoms o fever o headache o confusion and obtundation (dulled senses) o dysphasia (impaired speech) o seizures and paresis vaccine for Venezuelan equine encephalitis (VEE) is available Smallpox virus vaccine no longer is produced Aerosol exposure signs and symptoms o viremia (viruses in blood) o malaise o fever o headache and/or delirium o prolonged rash Allergens mite/insect particles, epithelium, hair, urine, feces, and powdered enzymes could cause respiratory symptoms, conjunctivitis (pink eye), and/or dermatitis (skin inflamation) Others Clostridium botulinum Yersinia pestis (plague)
  • 14. Radiological Effects of radiation on bone, GI, CNS TRACEM-P Self-Protection o Time, distance, shielding o Radiologic detecting equipment, assume dissemination radiological dispersion o practical and difficult to detect o symptoms are delayed o treatable if early detection Devices o Military nuclear device o Improvised o Radiological dispersal device (dirty bomb) o Sabotage
  • 15. Incendiary variety of devices o may involve attacks on a fixed target or group of people o assume designed to disperse bio, chem, radiologic materials TRACEM-P Self-Protection o preblast vs postblast Blast injury patterns o Lung injury - bradycardia, apnea, and hypotension o Ear injury - tympanic membrane (loss of hearing, blood, ringing) o Abdominal injury o Brain injury - concussion or mild traumatic brain injury (MTBI)
  • 16. Boston Marathon Bombings responders performed selfless and heroic acts of care and compassion, situation was special due to large amount of EMS who were on hand for the marathon itself and were on the scene within seconds, race tents were utilized as cold zone o Doctors were "pulling ball bearings out of people in the emergency room...a terrifying scene of shattered glass, bloodstained pavements and severed limbs." -terrorism expert o "Somebody's leg flew by my head. I gave my belt to stop the blood" -John Ross o "They just started bringing people in with no limbs" -Tim Davey o "They just kept filling up with more and more casualties...Most everybody was conscious.They were very dazed." -Lisa Davey o "This is something I've never seen in my 25 years here ... this amount of carnage in the civilian population." -Alisdair Conn, chief of emergency services at Massachusetts General Hospital
  • 17. CNN Report on First Responders
  • 18. We Can't Always Help unexploded bombs were rampant Adrian judged scene was not secure The conflict between personal priorities and the call to duty can be significant o sometimes we can become part of the problem not aid solution "They were disoriented and dehydrated from the race, and really couldn't talk much...I couldn't do very much for them, other than stay with them until friends arrived to help them home." o -EMT Adrian Will-Orrego, junior at Northeastern
  • 19. Adam Lane We had just left the area a minute before the explosion...We could feel the concussive energy of the primary blast wave At first we didn't know what it was...We saw a lot of people run by. It seemed that it was almost instantaneous that medical responders were all over the place, tending to the wounded I made the right decision to stay with my friends and go help other runners who were not injured but were still shocked and exhausted by what happened You realize after something like this, there is a lot that is just beyond your control...Had we been delayed a few minutes, things could had been very different o -Adam Lane EMT, PA student studying at the Massachusetts College of Pharmacy and Health Sciences
  • 20. Marathon: IEDs Improvised Explosive Device: o homemade bomb or destructive device created to destroy, incapacitate, harass, or distract wide variety of forms can be thrown, placed, or concealed composed of package o e.g. vehicle, a package, cans, backpacks, vests etc. initiating system o set off the main charge to make it detonate o e.g. cell phone, toy RC, etc. main charge o almost always includes a blasting cap and batteries o any type of battery can be used (e.g. 9- volt, AA, car batteries, etc.)
  • 21. IED Deployment Triggered Over time: allow enemy to escape or to target victims On command: choose the optimal moment, used against mobile targets with established pattern o include wires or radio controlled devices Victim o switches include pull or trip, pressure, pressure release, movement-sensitive, light- sensitive, proximity Deployment Techniques disguised in a variety of things Multiple IEDs can be linked together with detonation cord o charges detonate simultaneously often secondary devices and multiple explosions to increase victims o scene safety! gunfire, small bombs, and other distraction tactics can bait victims into the kill zone of a second IED Multiple locations are common with IED bombers so command officers must be mindful of their resources
  • 22. Specific IEDs VBIED: parked vehicle in a high traffic area VBIEDS: suicide driver VBIED o hard to detect and stop o bomber -mobile, able to choose time, place, and victims Suicide Bombers Personal Borne IEDS (PBIED) attack with an explosive vest, belt, or baggage attached to person o commonly hold up to 12 lbs of explosives (can be as high as 45) and incorporate fragment materials into the design o potential attack attempting to circumvent security checkpoint or gate wearing too much clothing for the weather suspicious bulges in clothing
  • 23. Works Cited EMS1 Staff. 3 dead, dozens injured after Boston Marathon explosions. EMS1. N.p., 15 Apr. 2013. Web. 19 Apr. 2013. <http://www.ems1.com/mass-casualty-incidents-mci/articles/1432242-2-dead- dozens-injured-after-Boston-Marathon-explosions/>. French, Glenn. Boston bombings: IED recognition for patrol officers. PoliceOne. N.p., 17 Apr. 2013. Web. 19 Apr. 2013. <http://www.policeone.com/terrorism/articles/6199597-Boston-bombings-IED- recognition-for-patrol-officers/>. Hsieh, Art. Boston bombings: EMT stories from the scene. EMT1. N.p., 18 Apr. 2013. Web. 19 Apr. 2013. <http://www.ems1.com/columnists/art-hsieh/articles/1434117-Boston-bombings-EMT-stories-from- the-scene/>.
  • 24. Works Cited Count. Kaye, Randi. CNN News Report. Youtube. N.p., 17 Apr. 2013. Web. 21 Apr. 2013. <http://www.youtube.com/watch?v=fRD90hRb5gQ>. Limmer, Daniel, et al. "EMS Responce to Terrorism." Emergency Care. Ed. Edward T. Dickinson. 12th ed. Upper Saddle River: Pearson Education, 2012. 1063-97. Print. Morse, Michael. The Boston bombings: EMS efforts made me proud, humble. EMT1. N.p., 16 Apr. 2013. Web. 19 Apr. 2013. <http://www.ems1.com/columnists/michael- morse/articles/1432737-The-Boston-bombings-EMS-efforts-made-me-proud-humble/>. Stephens, Everett. EMS and Terrorism. Medscape. N.p., 24 July 2008. Web. 19 Apr. 2013. <http://emedicine.medscape.com/article/765132-overview#showall>.