Chapter 50 Terrorism Injured PatientsUnit SummaryThis chapter describes how you can prepare to respond to events relating to terrorism by discussing types of terrorist events and patient management. You will also learn the signs, symptoms, and treatment of patients who have been exposed to chemical, biologic, radiologic, nuclear, and explosive (CBRNE) agents or injured by a suicide bomb and explosive attacks. Lastly, issues of responder health and safety at the scene of a terrorist attack will be discussed in detail.

National EMS Education Standard CompetenciesEMS Operations

Knowledge of operational roles and responsibilities to ensure patient, public, and personnel safety.

Mass-Casualty Incidents Due to Terrorism and Disaster

• Risks and responsibilities of operating on the scene of a natural or man-made disaster. (pp 2289-2311)

Knowledge Objectives1. List key questions to consider when responding to a terrorist event. (pp 2289-2290)

2. Define international and domestic terrorism. (pp 2290-2291)

3. Define and specify types of terrorist groups. (pp 2291-2293)

4. List various examples of terrorist agendas. (pp 2291-2293)

5. Discuss the color-coded advisory system’s replacement with the National Terrorism Advisory System (NTAS). (pp 2293-2294)

6. Discuss what actions paramedics should take during the course of their work to heighten their ability to respond to and survive a terrorist attack. (pp 2293-2297)

7. List various examples of potential terrorist targets. (pp 2293-2294)

8. Discuss factors to consider when responding to a potential weapon of mass destruction incident, including preincident indicators, the type of location, the type of call, the number of patients, and victims’ statements. (pp 2293-2297)

9. Discuss key response actions to take at the scene of a terrorist event, including establishing scene safety, ensuring personal protection, notification procedures, requests for resources, and establishing or working within command. (pp 2294-2297)

10. Define secondary device, and discuss the importance of continually reassessing scene safety. (p 2297)

11. List the four main categories of weapons of mass destruction. (p 2297)

12. Discuss specific types of devices used by terrorists, including explosives, ammonium nitrate, and suicide bombers. (pp 2297-2298)

13. Define terms related to chemical agents, including persistency, volatility, contact hazard, and vapor hazard. (p 2298)

14. Describe specific vesicant agents. (pp 2298-2299)

15. Discuss signs, symptoms, and treatment for vesicant exposure. (pp 2298-2299)

16. Describe specific pulmonary agents. (pp 2299-2300)

17. Discuss signs, symptoms, and treatment for exposure to a pulmonary agent. (pp 2299-2300)

18. Describe specific nerve agents. (pp 2300-2302)

19. Discuss signs, symptoms, and treatment for exposure to a nerve agent. (pp 2300-2302)

20. Describe specific industrial chemicals and insecticides. (pp 2302-2303)

21. Discuss signs, symptoms, and treatment for exposure to a cyanide agent. (pp 2302-2303)

22. Define terms related to biologic agents, including dissemination, disease vector, communicability, and incubation. (p 2303)

23. Describe signs, symptoms, and treatment for smallpox. (pp 2304-2305)

24. Describe signs, symptoms, and treatment for viral hemorrhagic fevers. (pp 2304-2306)

25. Describe signs, symptoms, and treatment for inhalation and cutaneous anthrax. (p 2306)

26. Describe signs, symptoms, and treatment for plague. (pp 2306-2307)

27. Describe signs, symptoms, and treatment for exposure to botulinum toxin. (p 2307)

28. Describe signs, symptoms, and treatment for exposure to ricin. (pp 2307-2308)

29. Define syndromic surveillance, and discuss its importance during a potential terrorist event. (p 2308)

30. Define radiation, and describe the difference between alpha, beta, gamma, and neutron radiation. (pp 2309-2310)

31. Describe what a radiologic dispersal device, or dirty bomb, is and how it is used for terrorism. (p 2310)

32. List protective measures to take when responding to a radiologic event. (p 2311)

33. Discuss medical management of a patient who was potentially exposed to radiation. (p 2311)

Skills Objectives1. Demonstrate how to use a nerve agent antidote kit. (p 2302)

Readings and PreparationReview all instructional materials including Chapter 50 of Nancy Caroline’s Emergency Care in the Streets, Seventh Edition, and all related presentation support materials.

Support Materials• Lecture PowerPoint presentation

• Case Study PowerPoint presentation

Enhancements• Direct students to visit the companion website to Nancy Caroline’s Emergency Care in the Streets, Seventh Edition, at http://www.paramedic.emszone.com for online activities.

Cultural considerations Terrorism can be a very sensitive topic for some ethnic cultures as well as adherents of differing types of religions and beliefs. Discussions that turn into accusations have no place in learning.

Teaching TipsAs mentioned in the cultural considerations section above, a discussion of terrorism can easily become a discussion on culture, ethnicity, and religious beliefs, which some may find offensive.

It is very important to discuss the “act of terrorism” rather than picking a culture and/or belief that may have perpetuated it.

Unit ActivitiesWriting activities: Asign students one of the five exposure methods: chemical, biologic, radiologic, nuclear, and explosive (CBRNE). Students are to discuss the types of agents that may be used and what effects would be seen in patient care.

Student presentations: Have students present the results of their written report or group activity.

Group activities: Divide students into groups. Have each group determine potential terrorist targets within your local area as well as county/statewide. Discussion should include why each group made their selections.

Visual thinking: Have students identify some of the signs and symptoms that may be present when dealing with an exposure to a terrorist event. This can be accomplished using pictures from the chapter or those that can be found on the internet.

Pre-Lecture

You are the Medic “You are the Medic” is a progressive case study that encourages critical-thinking skills.

Instructor DirectionsDirect students to read the “You are the Medic” scenario found throughout Chapter 50.

• You may wish to assign students to a partner or a group. Direct them to review the discussion questions at the end of the scenario and prepare a response to each question. Facilitate a class dialogue centered on the discussion questions and the Patient Care Report.

• You may also use this as an individual activity and ask students to turn in their comments on a separate piece of paper.

Lecture

I. IntroductionA. Terrorist attacks have sharply increased over the last decade, happening several

times a week around the world.1. International and domestic terrorist groups have increased their targeting of civilian

populations.

2. You should be prepared mentally and physically for the possibility of an attack.

B. Terrorism threatens the health and safety of paramedic responders.1. During the sarin attacks in Tokyo in 1996, 10% of the paramedics responding were

sickened because they didn’t wear the proper personal protective equipment (PPE).

2. The September 11, 2001, attacks brought health and safety to the forefront.

a. 450 emergency responders, 15% of the total victims, were killed that day.

b. Many more paramedics and EMTs were injured, developed chronic disorders, or experienced depression and physiologic problems.

3. EMS providers are encouraged to seek additional training and participate in drills to develop the skills needed to respond to a terrorist event.

II. Terrorism

A. Terrorism is defined by the US Department of Justice as a violent act dangerous to human life, in violation of the criminal laws of the United States or any state or subdivision thereof, to intimidate or coerce a government, the civilian population, or any segment thereof, in furtherance of political or social objectives.1. Mass destruction, assassinations, and kidnappings with the purpose to influence or affect

a government are also defined as terrorism.

2. Terrorism is often used as a form of asymmetric warfare.

a. Groups wage war against populations with unconventional weapons and covert tactics that are unequal to military resources or capabilities.

3. Terrorists tend not to discriminate when selecting their targets and have intentionally attacked children.

a. In 2004, 30 heavily armed terrorists and suicide bombers took over a school in Beslan, Russia, holding children hostages over 3 days.

i. 334 hostages were killed, many children.

b. In 2011, a lone terrorist exploded a car bomb in Oslo and then opened fire at a summer camp, killing 69 people.

B. International terrorism1. International terrorism (cross-border terrorism): Acts of terror committed by foreign

agents

2. Categorized into subgroups:

a. Non-state-supported terrorism

i. Terrorism that is either indigenous or transnational

ii. Doesn’t receive direction or support from a government

b. State-sponsored terrorism

i. Funded or supported by a government

ii. Government holds close ties with the group, but the group still acts independently.

c. State-directed terrorism

i. Terrorists act as direct agents of the government.

C. Domestic terrorism1. Domestic terrorism: Perpetrators are citizens of the country that is being attacked.

2. Examples of domestic terrorism:

a. The Centennial Olympic Park bombing in Atlanta during the 1996 Summer Olympics.

i. Over 100 people were injured and 2 people were killed.

b. The destruction of the Alfred P. Murrah Federal Building in Oklahoma City in 1995

i. 168 people were killed, including 19 children.

c. Post-9/11 attacks in the United Kingdom and plots in the United States:

i. The thwarted 2006 Sears Tower plot

ii. The thwarted 2006 Toledo, Ohio, terror plot

iii. 2007 Fort Dix, New Jersey, attack plot

iv. 2008 bombing of Armed Forces recruiting office in Times Square

v. 2009 Fort Hood, Texas, shooting that killed 13 people and wounded 30

vi. 2009 Little Rock, Arkansas, Armed Forces recruiting office shooting that killed one recruiter and injured a second

vii. The thwarted 2009 New York subway and United Kingdom plots

viii.The failed 2010 Times Square car bombing

ix. 2010 Austin, Texas, IRS office attack that killed one worked and the suicide attacker who flew his plane into the building

x. The failed 2010 Portland, Oregon, car bomb plot

xi. 2011 mail bombing of two Maryland government buildings

D. Types of terrorist organizations1. Terrorist organizations can be defined as one or more of these:

a. Violent religious groups/doomsday cults

i. Often seek apocalyptic violence or mass murder

ii. Believe in eradicating or cleansing a region (or Earth) of people who don’t practice their faith

b. Extremist political/social groups

i. Violent separatist groups who are looking for political, economic, or social freedom

ii. May seek to kill or evict foreigners, migrants, or people with different ethnic, racial, sociologic, and/or cultural backgrounds

iii. Use terror to influence economic or immigration politics and the drawing and redrawing of geopolitical borders

c. Technology or “cyber” terrorists

i. Attack technologic infrastructure using technology to draw attention to their cause

ii. It is common for them to “hack” into computer systems and introduce corruptive computer programs.

iii. They can extract information, but they can also cause harm to the computers and the machines or processes they control (security systems).

iv. It is hard to detect and shut down these attacks early, if at all.

v. These terrorists tend to work in groups.

d. Single-issue terrorist groups

i. These groups include anti-abortion, animal rights, anarchists, and eco-terrorists.

ii. They threaten or use violence as a way to advance their views and goals.

iii. These groups usually represent the violent side of a non-violent group that wants to effect change through legal and socially acceptable means.

(a) Look for immediate and effective response to their demands when the nonviolent methods are seen as ineffective

e. Narcoterrorists

i. Uses terror to take control of a region, its politics, or government with a goal of manufacturing, distributing, and selling drugs without prosecution

ii. Often target military, police, anti-drug politicians, government officials, and innocent civilians in order to gain control from local authorities

iii. The revenue of the drugs makes the groups more heavily armed, organized, and funded than the local authorities.

f. Other subcategories include:

i. Hate groups

ii. Patriot groups

iii. Militia groups

iv. Common-law groups

v. Cult groups

vi. Single-issue groups

vii. Lone wolves

2. Some terrorist groups may have similar traits to several of these categories or join forces with other groups that use different methods but have the same goal or target.

3. Al Qaeda is the most infamous international terrorist organization.

a. Their influence and membership has spread across the Middle East over the last two decades.

b. They are known for their violent, simultaneous, coordinated attacks.

i. This is in place to confuse, spread thin, and overwhelm emergency response to the incidents.

c. They exhibit trends toward apocalyptic violence to affect a combination of political, geopolitical, and religious goals.

4. Terrorist groups thrive in regions with weak or corrupt regional governments.

a. Many groups establish training camps and operation bases in remote, austere locations.

5. Most attacks require multiple terrorists or “actors” that work together.

a. These people are recruited, trained, financed, and provided with equipment and intelligence.

III. Paramedic Response to TerrorismA. Recognizing a terrorist event (indicators)

1. Acts of terror are usually covert, and the public safety community typically has no prior knowledge of where, when, or the nature of the attack.

2. It is important that you can recognize risks and high-value targets within your jurisdiction.

3. Some potential high-value targets for terrorists include:

a. Military bases/installations and military recruiting centersb. Rail and metro transport systemsc. Large bus depotsd. Airports/seaportse. Chemical plants/chemical transfer stations or chemical transportationf. Petrochemical storage or transportationg. Dams and reservoirs

h. Bio labs

i. All large gathering spaces/places

i. Stadiumsii. Sporting arenasiii. Parade routes

j. Government buildings

i. Court houses

ii. Federal buildings

iii. Public safety headquarters

k. Hospitals

l. Large religious venues

i. Church

ii. Mosque

iii. Temple

iv. Synagogue

m. Large shopping centers and malls

n. Large demonstrations or rallies

o. Large financial centers

i. Financial markets or exchanges

p. National symbols

i. Monuments

ii. Memorials

4. The National Advisory System (NTAS) has replaced the color-coded Homeland Security Advisory System which was instituted in 2002.

a. NTAS alerts apply to the United States and its territories.

b. It alerts responders to the potential for an attack and specifics about the threat.

i. Who will be potentially affected

ii. Geographic area

iii. Transportation concerns

iv. The nature of the threat

c. Alerts will include steps that people or communities can take to protect themselves.

d. The alert will specify if the threat is:

i. Elevated, meaning there is not specific information about the timing or location

ii. Imminent, meaning the threat is believed to be impending or expected to occur soon

e. Alerts are posted at DHS.gov/alerts and distributed through social media.

f. The DHS has not issued specific recommendations for EMS personnel to follow in response to the alert system.

i. You should know the threat level everyday, and take precautions throughout normal daily duties.

5. While on duty you must make appropriate decisions regarding the potential threat of terrorism, observing:

a. Preincident indicators

i. Has the NTAS posted a threat warning?

ii. Has violent political activism increased recently?

iii. Are you aware of any credible threats made against the location, gathering, or occasion?

b. Type of location

i. Is the location a monument, infrastructure, government building, or specific location like a temple?

ii. Is there a large gathering like a parade or political demonstration?

iii. Is there a special event like a college football game?

c. Type of call

i. Is there a report of explosion or suspicious device nearby?

ii. Does the call come in as someone having unexplained coughing and difficulty breathing?

iii. Are there reports of people fleeing the scene?

d. Number of patients

i. The most important clue is if there multiple patients with similar signs and symptoms.

e. Victims’ statements

i. The second best indicator is if people fleeing the scene are giving statements like:

(a) “Everyone is passing out.” (b) “There was a loud explosion.” (c) “There are a lot of people shaking on the ground.”

B. Response actions1. When you suspect that there is a terrorist act or a WMD has been used take these actions

to ensure your safety and put yourself in the position to help the community:

a. Ensure scene safety and personal safety.

b. Notify your dispatch and/or supervisor of the incident.

c. Request additional specialized resources.

d. Establish command.

e. Initiate multiple-casualty incident procedures.

2. Ensure the scene is safe, and do not enter if you have any doubt that it is not safe.

a. With a WMD scene, it is safe to assume you will not be able to enter where the event has happened.

b. The best location for staging is upwind and uphill from the incident.

c. Wait for assistance from trained personnel who can assess and manage the scene.

d. Remember:

i. Failure to park your vehicle at a safe location can place you and your partner in danger.

ii. If your vehicle is blocked in by other emergency vehicles or damaged by a secondary device you cannot provide patients with transportation or escape yourself.

3. Research shows that responder health and safety can suffer more than usual during WMD incidents.

a. These events can cloud decision making, and paramedics can develop tunnel vision.

i. A person focuses on one aspect instead of the overall picture.

b. You need the following key resources in a potentially hazardous scene:

i. Awareness of measures to take for self-preservation

ii. A culture of safety within your organization

iii. Previous knowledge, fit testing, experience, and comfort using multiple types and brands of PPE

iv. The proper PPE

v. Self-enforcement of all protective measures

4. The best form of protection is preventing yourself from coming in contact with the agent.

a. Your greatest threat is contamination and cross-contamination.

i. Contamination: Exposure to or contact with the WMD

ii. Cross-contamination: Contact with a contaminated person who hasn’t been decontaminated

b. Decontamination is important to patients who have been exposed to or contaminated with a chemical, biologic, radiologic, nuclear agent, or explosive.

i. If EMS personnel have been trained and have the correct PPE, they may be involved in decontamination.

5. Notification procedure/resource requests

a. As soon as you suspect a terrorist or WMD event, notify the dispatcher.

b. Vital information needs to be communicated effectively.

i. Nature of the event

ii. Any additional resources that may be required

iii. Estimated number of patients

iv. Upwind or optimal route of approach

c. Establish a safe staging area for other units to converge.

i. Take into consideration access and exit routes.

d. HazMat teams should be requested as early as possible.

i. Their teams take longer because of assembly and dispatch of equipment.

ii. HazMat teams are often shared among jurisdictions and may have to travel a long distance.

iii. Keep in mind there may be more than one device or agent present.

6. Command

a. If the Incident Command System (ICS) is already in place, find the medical staging supervisor for your assignment.

b. Paramedics who arrive on the scene first may need to establish “EMS or Medical Command” until additional personnel arrive.

c. Depending on the circumstances you and other paramedics may act as:

i. Medical branch supervisors

ii. Triage supervisors

iii. Treatment supervisors

iv. Transportation or logistic supervisors

v. Staff

d. Initial tasks that the first arriving paramedic must perform are:

i. Report to incident command post (in unified command).

ii. Establish a medical branch under the operation section.

iii. Determine the scope of the incident.

(a) Type of incident(b) Hazards to responders and victims(c) Number of patients/deceased(d) Safe access, egress, and staging locations(e) Gather information on decontamination area(s), and hot, warm, and cold

zones.

iv. Regularly gather and disseminate information to dispatch.

v. Establish and assign a supervisor for the following areas:

(a) Decontamination(b) Treatment (c) Transportation (departing units)(d) Staging (arriving personnel and units)(e) Rehabilitation

vi. Report all EMS activities to the operations section chief.

e. Paramedics should expect heavy police presence at each EMS sector for several reasons:i. To provide site security so media and onlookers don’t interfere with the wounded

or their careii. To monitor all victims in the event that an accomplice is among the injured.iii. To canvas witnesses who may have valuable information

f. Paramedics should fully comply with all law enforcement requests.

i. Investigators may question patients during triage, treatment, or transport to a hospital to gather information.

7. Secondary device or event (reassessing scene safety)

a. Terrorists often plant additional explosives, or secondary devices, to go off after the initial bomb.

i. Intended to injure responders and secure media coverage.

ii. It is every paramedic’s responsibility to assess and reassess the scene for safety.

iii. Never become so involved in a task that you do not look around to reassess the safety of the scene.

IV. Weapons of Mass Destruction

A. A weapon of mass destruction (WMD) is anything used as a weapon designed to bring about mass death, casualties, and/or massive damage to property and infrastructure. 1. WMDs can be grouped into four major categories.

a. Explosives/incendiary devices (preferred WMD for terrorists)

b. Chemical

c. Biologic

d. Radiologic/nuclear weapons

2. WMDs may include:

a. Poison gasb. Grenadesc. Rocketsd. Missiles with a propellant charge or explosivee. Mine or similar device

B. With terrorist groups changing their motives and tactics to apocalyptic, indiscriminate killing, WMDs are highly desirable. 1. WMDs are easy to obtain or create and are geared towards killing large numbers of

people.

a. Technical recipes for making nuclear, biologic, and chemical (NBC) weapons and explosive devices can be found readily on the internet.

V. Explosives/Incendiary WeaponsA. Explosives are the most common weapons used by terrorists.

1. Incendiary agents (i.e. acetone) are combined with chemicals to produce explosives capable of mass destruction.

a. These bombs can go off on public buses, trucks, or in parking garages and can be destructive.

B. Ammonium nitrate or “fertilizer” bombs1. Ammonium nitrate is commonly used as an industrial-grade fertilizer

2. Often needs a special license to purchase because it can be mixed with an easily attainable component like diesel to create an extremely explosive compound.

a. An ammonium nitrate and fuel oil mixture (ANFO) was used in the attack on the Alfred P. Murrah Federal Building in Oklahoma City in 1995.

b. An ANFO bomb was used in the 1993 Al Qaeda attack on the World Trade Center.

C. Suicide bombers (human bombs)1. The weapon of choice for modern day terrorists

2. Merges the destructive power of military-grade explosives with the timing and accuracy of human guidance and triggering.

a. Low-cost, low-technology, and low-risk weapon

b. Easily concealed, carried, and delivered with accuracy

3. Recruits are readily available.

a. They rely on the element of surprise and familiarity with the targeted area.

4. These types of attacks are sometimes recorded as propaganda to perpetuate fear.

a. Outside of the United States, media outlets have little self-censorship and will broadcast graphic videos made by terrorists.

VI. Chemical AgentsA. Chemical agents are man-made substances that can have devastating effects on

living organisms.1. Produced in multiple forms depending on the route of exposure and dissemination

technique:

a. Liquid

b. Powder

c. Vapor

2. First developed in World War I

3. Can be categorized as:

a. Vesicants or blister agents

i. Mustard gas

ii. Lewisite

b. Respiratory or choking agents

i. Phosgene

ii. Chlorine

c. Nerve agents

i. Sarin

ii. Soman

iii. Tabun

iv. V agent

d. Metabolic or blood agents

i. Hydrogen cyanide

ii. Cyanogen chloride

e. Irritating agents

i. Mace

ii. Chloropicrin

iii. Tear gas

iv. Capsicum/pepper spray

v. Dibenzoxazepine

4. Chemical weapons have several classifications

a. Properties or characteristics of an agent:

i. Liquid

ii. Gas

iii. Solid

b. Persistency and volatility describe on how long the agent will stay on a surface.

i. Persistent or nonvolatile agents can remain for usually longer than 24 hours.

ii. Nonpersistent or volatile agents evaporate fast when in optimal temperature.

iii. Highly persistent agents can remain in the environment for weeks or months.

iv. Highly volatile agents will evaporate within minutes to seconds.

c. Route of exposure describes how the agent most effectively enters the body.

i. Vapor hazards enter the body through the respiratory tract as vapors.

ii. Contact hazards or skin hazards enter the body through the skin.

B. Vesicants (blister agents)1. Primary route of exposure is the skin.

a. If left on skin or clothing for long enough vesicants can produce vapors that can enter the respiratory tract.

2. Cause burnlike blisters that form on skin and in respiratory tract

3. Agents consist of:

a. Mustard (H)

b. Lewisite (L)

c. Phosgene oxime (CX)

d. H, L, CX are military designations of the chemicals.

4. Cause the most damage to moist areas of the body

a. Armpits

b. Groin

c. Respiratory tract

5. Signs of exposure on the skin include:

a. Skin irritation, burning, and reddening

b. Immediate intense skin pain

i. With L and CX

c. Formation of large blisters

d. Gray discoloration of skin

i. A sign of permanent damage seen with L and CX

d. Swollen and closed or irritated eyes

e. Permanent eye injury

i. Including blindness

6. Signs of inhalation of vapors include:

a. Hoarseness and stridor

b. Severe cough

c. Hemoptysis

i. Coughing up blood

d. Severe dyspnea

7. Sulfur mustard (agent H)

a. A brownish, yellowish oily substance

b. Generally considered persistent

c. When released, it has the distinct smell of garlic or mustard

d. Quickly absorbed into the skin and/or mucous membranes.

i. As it is absorbed it begins an irreversible process of damage to the cells.

ii. Occurs within seconds

iii. Damage to the underlying cells takes place within 1 to 2 minutes.

e. Considered a mutagen

f. Generally a patient will not produce signs or symptoms until 4 to 6 hours after exposure.

g. The affected area will progressively redden and develop into large blisters.

i. Blisters are similar in shape and appearance to those associated with thermal second-degree burns.

ii. The skin covering the area is considered contaminated until decontaminated by trained personnel.

h. Also attacks vulnerable cells within the bone marrow

i. This depletes the body’s ability to reproduce white blood cells.

i. The main complication is secondary infection.

i. The depletion of white blood cells leaves the patient with decreased resistance to infection.

j. Regarded as a persistent but it does release vapors.

i. Creates upper and lower airway compromise

ii. Damages and swells the airways

8. Lewisite (L) and phosgene oxime (CX)

a. Produce similar blister wounds to sulfur mustard

b. Highly volatile

c. Produce immediate and intense pain and discomfort after contact is made.

d. Patient may have grayish discoloration at the contaminated site.

e. Tissue damage also occurs with exposure.

i. They do not cause secondary cellular injury associated with sulfur mustard.

9. Vesicant agent treatment

a. There are no antidotes for sulfur mustard or CX exposure.

b. BAL (British Anti-Lewisite) is the antidote for agent L.

i. Not carried by civilian EMS

c. Ensure that a patient has been decontaminated before ABCs are initiated.

i. Usually by soap and copious amounts of water

d. Initiate transport, and gain IV access as soon as possible.

e. Typically burn centers are best equipped to handle the wounds and infections produced by vesicants.

C. Pulmonary agents (choking agents)1. Gases that cause immediate harm to those exposed

2. Primary route of exposure is through the respiratory tract.

a. Inhalation or vapor hazard

3. Once in the lung they damage the lung tissue and fluid leaks into the lungs.

a. These agents produce respiratory-related symptoms.i. Dyspneaii. Tachypneaiii. Pulmonary edema

4. Chlorine (CL)

a. CL was the first agent ever used in chemical warfare.

b. Distinct odor of bleach

c. Creates a green haze when released as a gas

d. Initially produces upper airway irritation and choking sensation

e. Symptoms that a patient may experience later:

i. Shortness of breath

ii. Chest tightness

iii. Hoarseness and stridor due to upper airway constriction

iv. Gasping and coughing

f. Patients with serious exposure may experience:

i. Pulmonary edema

ii. Complete airway constriction

iii. Death

g. When household bleach (CL) is mixed with ammonia it creates an acid gas with similar effects.

5. Phosgene

a. Not to be confused with phosgene oxime (blistering agent, vesicant)

b. Produced from chemical welfare and as a product of combustion from:

i. A textile factory or house

ii. Metalwork

iii. Burning Freon

c. You may encounter a patient who is exposed during a normal care or fire scene.

d. Potent with delayed symptoms, usually takes hours

i. Smells similar to freshly cut grass or hay

ii. Much more of the gas is able to enter the body unnoticed.

e. Initial symptoms of mild exposure:

i. Nausea

ii. Chest tightness

iii. Severe cough

iv. Dyspnea on exertion

f. Symptoms of severe exposure:

i. Dyspnea at rest

ii. Excessive pulmonary edema

(a) Patient will expel fluid from their lungs.(b) Patient may become hypovolemic and subsequently hypotensive.

6. Pulmonary agent treatment

a. The best initial treatment is to remove the patient from the contaminated atmosphere.

i. Done by trained personnel in the correct PPE

b. Aggressive management of the ABCs should be initiated.

i. Pay attention to oxygenation, ventilation, and suctioning.

c. Patient activity worsens condition faster.

d. There is no antidote to counteract pulmonary agents.

i. Perform ABCs.

ii. Gain IV access.

iii. Allow patient to rest in comfort with head elevated.

iv. Initiate rapid transport.

e. Pharmacotherapy may include standard treatment for:

i. Bronchospasm

ii. Pulmonary edema

iii. Potential corticosteroid use

iv. Positive-pressure ventilation with supplementary oxygen

D. Nerve agents1. Designed to kill large numbers of people with small quantities

a. Can cause cardiac arrest within seconds of exposure

2. Belong to a class of chemicals called organophosphates.

a. Smaller strengths can be found in:

i. Household bug sprays

ii. Agricultural pesticides

iii. Some industrial chemicals

b. At greater strengths they can harm the brain and nervous system of animals and humans.

c. They block the essential enzyme, cholinesterase, in the nervous system from working.

i. Causes the body’s organs to be overstimulated and burnout

3. G agents

a. Came from early nerve agents developed by German scientists in the period after WWI and into WWII

b. G agents listed from high volatility to low volatility:

i. Sarin (GB)(a) Colorless and odorless liquid(b) Turns from gas to liquid from seconds to minutes at room temperature(c) Highly lethal with an LD50 of 1,700 mg/70 kg (1 drop, depending on purity)

(1) LD50 is the amount of product that will kill 50% of people exposed at this level.

(d) Primarily a vapor hazard(e) Especially dangerous in enclosed environments(f) When the agent contacts skin it is quickly absorbed and evaporates.(g) When on clothes GB has the effect of off-gassing.

(1) The vapors are continuously released over time like perfume.ii. Soman (GD)

(a) Twice as persistent and five times as lethal as GB (b) Has a fruity odor and no color(c) Both a contact and inhalation hazard(d) An additive causes it to bind to the cells so that it attacks faster than other

agents.(1) The binding (aging) is irreversible making it harder to treat exposed

patients.iii. Tabun (GA)

(a) Half as lethal and 36 times more persistent than GB (b) Has a fruity smell and appears similar to GB(c) Components are easy to acquire and easy to manufacture.(d) Both a contact and inhalation hazard

iv. V agent (VX)(a) Clear oily agent with no odor; resembles baby oil(b) Has similar chemical properties to the G series agents

(1) VX is over 100 more times lethal than GB and is extremely persistent.

(c) So persistent it can remain unchanged for weeks to months.(d) Primarily a contact hazard because it lets off little vapor.(e) Easily absorbed in the skin, and the residue that remains is hard to

decontaminate.

4. Once the agent has entered the body through skin contact or respiratory system there will be a pattern of predictable symptoms.

a. The severity of symptoms depends on the route of exposure and amount the patient was exposed to.

b. Symptoms are described using:

i. Military mnemonic SLUDGEM (a) Salivation(b) Lacrimation(c) Urination(d) Defecation(e) GI distress(f) Emesis(g) Miosis

ii. Medical mnemonic DUMBELS(a) Defecation(b) Urination(c) Miosis(d) Bradycardia, bronchorrhea(e) Emesis(f) Lacrimation(g) Salivation

5. Only a handful of medical conditions are associated with the miosis (bilateral pinpoint constructed pupils) that is seen with nerve agent exposure.

a. Suspected stroke

b. Basilar skull fracture

c. Direct light to both eyes

d. An opiate drug overdose

6. Seizures that are associated with nerve agent exposure are unlike those experienced by people who have a history of seizures.

a. The patient will continue to seize until death or until treatment is given.b. Nerve agent antidote is DuoDote or MARK 1.

7. Nerve agent treatment

a. Fatalities from severe exposure occur as a result of respiratory complications that lead to respiratory arrest.

i. After decontamination you must aggressively treat these patients.

ii. Managing the ABCs is the best and most important treatment that you can provide.

iii. Seizing patients require the nerve agent antidote kits in addition to the ABCs.

b. There is an antidote for nerve agent exposure.

i. The DuoDote Antidote Kit contains a single injection of both atropine (2 mg) and 2-PAM chloride (pralidoxime chloride, 600 mg).

ii. MARK 1 kits (Nerve Agent Antidote kits (NAAK) are no longer made.

(a) Contains the same medication that is in DuoDote Antidote Kit, but they are administered with two separate auto-injectors.

iii. Medications are delivered using the same technique as the EpiPen auto-injector.

(a) Multiple doses may need to be administered.(b) Benzodiazepine may be administered due to seizure activity.

c. Atropine is used to block the nerve agent’s overstimulation of the body.

i. The nerve agent can stay in the body for a long time so 2-PAM chloride is used to eliminate the agent from the body.

ii. Many doses may need to be administered to see results. iii. If your service carries a NAAK, refer to your medical director and local protocols

for dose and usage information.

E. Industrial chemicals/insecticides1. Organophosphate, the basic chemical in nerve agents, is a common chemical in

insecticides but used in a lesser concentration.

2. Industrial chemicals do not have sufficient lethality to be effective WMDs.

a. To disseminate these chemicals, crop-duster planes could be used.b. The symptoms and medical management of organophosphate poisoning is identical

to nerve agents.

3. Metabolic agents (cyanides)

a. Hydrogen cyanide (AC) and cyanogen chloride (CK) affect the body’s ability to use oxygen.

b. Cyanide

i. A colorless gas

ii. Has an odor similar to almonds

iii. Effects begin on the cellular level and are quickly seen at the organ system level.

iv. They are commonly found in industrial settings and are produced in large quantities every year in the United States.

c. Symptoms found in AC and CK are very similar.

d. Low doses show symptoms including:

i. Dizziness

ii. Light-headedness

iii. Headache

iv. Vomiting

e. High doses show symptoms including:

i. Shortness of breath and gasping respirations

ii. Tachypnea

iii. Flushed skin color

iv. Tachycardia

v. Altered mental status

vi. Seizures

vii. Coma

viii.Apnea

ix. Cardiac arrest

f. When inhaled, symptoms will appear within several minutes, and death is likely unless the person is treated promptly.

4. Cyanide agent treatments

a. Cyanide binds with the body’s cells preventing oxygen from being used.

b. There are several medications that can act as antidotes, but not many services carry them.

c. Trained personnel wearing proper PPE should remove the patient from the source of exposure and remove all clothing to prevent off-gassing in the ambulance.

d. Support the patient’s ABCs, and gain IV access.

e. Severe exposure requires aggressive oxygenation and maybe even ventilation with supplementary oxygen.

i. When ventilating a patient exposed to a metabolic agent, always use a bag-mask device or oxygen-powered ventilator device.

ii. The agent can be passed on to you through mouth-to-mouth or mouth-to-mouth mask ventilations

f. If there is no antidote, initiate transport immediately.

5. The sense of smell is a bad tool to use to determine if a chemical agent is present.

a. Some people cannot smell the agent.

b. The odor could be derived from another source.

c. You should never enter a scene to “smell” to determine if a chemical agent is present.

VII. Biologic Agents

A. Biologic agents are organisms generally found in nature and can cause disease or death.1. When used by terrorists they are cultivated, synthesized, and mutated in a laboratory.

2. Primary types of biologic agents you may come into contact with during a biologic event are:

a. Viruses

b. Bacteria

c. Neurotoxins

3. When used as a WMD biologic agents pose many difficult issues.

a. Can be completely undetectable

b. Diseases caused by these agents are similar to other minor common illnesses.

4. Biologic agents can be spread in various ways.

a. Dissemination: How terrorists spread the agent

i. Poisoning water supply

ii. Aerosolizing the agent into the air or building ventilation system

b. Disease vector: An infected animal that spreads disease to another animal

5. Communicability: How easy it is for the disease to be spread from one human to another

a. When communicability is high, the person is considered contagious.

6. Incubation: Time between when a person becomes exposed to an agent and when they start showing symptoms

a. A patient can be contagious even though they aren’t showing signs.

B. Viruses 1. Germs that require a living host to multiply and survive.

a. Once in the body the virus will attack healthy cells and replicate itself to spread throughout the host.

b. Viruses survive by using vectors to move from one host to another.

2. Some viral agents have vaccines, but there is no treatment for a viral infection other than antivirals for some agents.

3. Because of the health threat the following viruses have, they have been used by terrorists:

a. Smallpoxi. A highly contagious diseaseii. Standard precautions should be used to prevent cross-contamination to health

care personnel.

iii. The last natural case in the world was in 1977.

iv. Before blisters show, the patient will have:

(a) High fever between 101°F and 104°F (b) Body aches and headaches

v. An easy way to differentiate smallpox from other skin disorders is the lesions’ size, shape, and location.

(a) All lesions are identical in development.(b) Blisters begin on the face and extremities and move toward the chest and

abdomen.

vi. The most contagious phase is when blisters begin to form.

vii. There is a vaccine to prevent smallpox, but it has been linked to medical complications and in rare cases, death.

(a) Only offered to first responders because of its risk.(b) If an outbreak were to occur the vaccine would be offered to people at risk.

b. Viral hemorrhagic fevers (VHFs)i. A group of diseases, including:

(a) Ebola(b) Rift Valley(c) Yellow fever viruses

ii. Causes blood in the body to seep out from the tissues and blood vesselsiii. Symptoms

(a) Begins with flulike symptoms(b) Progresses to internal and external hemorrhaging.

iv. Outbreaks are very rare in the United States.v. Standard precautions should be taken while treating these illnesses.vi. Mortality rates range from 5% to 90% depending on:

(a) The strain(b) Age and health of the patient(c) Availability of a modern health care system

C. Bacteria 1. Bacteria do not require a host to multiply and live.

2. Larger and more complex than viruses

a. Can grow up to 100 times larger than the largest virus.

b. Contain all the cellular structures of a normal cell and are completely self-sufficient.

3. Bacterial infections can be fought with antibiotics.

4. Most infections begin with flulike symptoms

a. Difficult to identify if the cause is a biologic attack or natural epidemic.

5. Inhalation and cutaneous anthrax

a. A deadly bacterium that lies dormant in a spore (protective shell)

i. The germ is released from the spore when exposed to optimal temperature and moisture.

b. Routes of entry are:

i. Inhalation

ii. Cutaneous

iii. Gastrointestinal (consuming food that contains spores)

c. The inhalation or pulmonary anthrax is the most deadly.

i. Presents as a severe cold

ii. 90% death rate if left untreated

d. There is an antibiotic to treat anthrax.

e. There is also a vaccine to prevent infections.

6. Plague-bubonic/pneumonic

a. No other infectious diseases has killed as many as the plague.

b. Its natural vectors are infected rodents and fleas.

i. A person becomes infected when bit by an infected flea or makes contact with an infected rodent or its waste.

c. Bubonic plague

i. Infects the lymphatic system

(a) The patient’s lymph nodes become infected and grow.(b) The glands will become round and grow to the size of a tennis ball, forming

buboes.

ii. The infection can spread through the body and lead to sepsis and possibly death if left untreated.

iii. This form of plague is not contagious.

d. Pneumonic plague

i. A lung infection, also known as pneumonia, resulting from inhalation of plague bacteria

ii. This form of the plague is contagious and has a higher death rate.

iii. Would be easier to disseminate (aerosolized)

D. Neurotoxins1. The most deadly substances known to humans

2. The strongest form is 15,000 times more lethal than VX and 10,000 times more lethal than GB.

3. Produced from:

a. Plants

b. Marine animals

c. Molds

d. Bacteria

4. Route of entry:

a. Ingestion

b. Inhalation from aerosols

c. Injection

5. Not contagious

6. Faster onset of symptoms

7. Have not been successful as a WMD

8. Botulinum toxin

a. The most potent neurotoxin

b. Produced from bacteria

c. When introduced to the body, the nervous system’s ability to function is affected.

i. The toxin will cause muscle paralysis beginning at the head and face and travel through the body downward.

ii. Accessory muscles and diaphragm will become paralyzed.

iii. Patient will go into respiratory arrest.

9. Ricin

a. Not as deadly as botulinum but still five times more lethal than VX

b. Derived from mash left from the castor bean

c. Causes pulmonary edema and respiratory and circulatory failure that leads to death

d. The toxin is quite stable and extremely toxic through many routes of exposure including inhalation.

i. 1 to 3 mg of ricin can kill an adult.

ii. Ingestion of one seed could kill a child.

e. All parts of the castor bean are poisonous, but the seeds are the most toxic.

f. Ingestion of castor beans causes a rapid onset of:

i. Nausea

ii. Vomiting

iii. Abdominal cramps

iv. Severe diarrhea

v. Followed by vascular collapse

g. Death will usually occur on the third day without appropriate medical intervention.

h. Least toxic by the oral route due to:

i. Poor absorption in the gastrointestinal tract

ii. Some expulsion of the agent caused by vomiting

i. Signs and symptoms of ingestion:

i. Fever

ii. Chills

iii. Headache

iv. Muscle aches

v. Nausea

vi. Vomiting

vii. Diarrhea

viii.Severe abdominal cramping

ix. Dehydration

x. Gastrointestinal bleeding

xi. Necrosis of liver, spleen, kidneys, and gastrointestinal tract

j. Signs and symptoms of inhalation:

i. Fever

ii. Chills

iii. Nausea

iv. Local irritation of eyes, nose, and throat

v. Profuse sweating

vi. Headache

vii. Muscle aches

viii.Nonproductive cough

ix. Chest pain

x. Dyspnea

xi. Pulmonary edema

xii. Severe lung inflammation

xiii.Cyanosis

xiv.Convulsions

xv. Respiratory failure

k. Treatment is supportive.

i. Early intubation, ventilation, and positive end-expiratory pressure, combined with treatment of pulmonary edema are appropriate.

ii. Due to the profound vomiting and diarrhea, IV fluids and electrolyte replacement treat dehydration.

E. Other paramedic roles during a biologic event1. Syndromic surveillance

a. The monitoring of patients presented to emergency departments and alternative facilities

b. The recording of EMS call volume and the use of over-the-counter medications

c. Local and state health departments monitor for an unusual increase of patients with influenza symptoms in order to discover an outbreak early.

d. EMS responders should report any unusual numbers of calls from patients with “unexplainable flu” from a particular area or region.

2. Points of distribution (PODs)

a. Strategically placed facilities that are preestablished for distribution of:

i. Antibiotics

ii. Antidotes

iii. Vaccinations

iv. Other medications and supplies

b. Medications may be delivered within 12 hours anywhere in the country in large containers known as “push packs” by the Center for Disease Control and Prevention.

i. Antibiotics

ii. Chemical antidotes

iii. Antitoxins

iv. Life-support medications

v. IV administration

vi. Airway maintenance supplies

vii. Medical/surgical items

c. Some regions have started to stockpile their own supplies to reduce time delay

d. Depending on local emergency management planning, paramedics may be asked to assist with delivery of medications to the public.

e. Paramedic’s role may include triage, treatment of seriously ill patients, and patient transport to the hospital.

VIII. Radiologic/Nuclear DevicesA. There are only two publically known incidents involving the use of a nuclear

device.1. During WWII, an estimated total of 214,000 were killed when Hiroshima and Nagasaki

were targeted with nuclear bombs.

2. Some nations with close ties to terrorist groups have obtained some degree of nuclear capability; however, it is easier to acquire radioactive materials or waste.

B. Radiation1. Ionizing radiation: Energy that is emitted in the form of rays or particles

a. Can be found in radioactive material (any material that emits radiation) like rocks and metals

2. Radioactive material is unstable.

a. It tries to stabilize itself by changing its structure in a natural process called decay.

i. As the substance decays it gives off radiation.

ii. The process of decay can take minutes to billions of years.

3. Energy emitted from a strong radiologic source has four categories.

a. Alpha

i. The least harmful penetrating type of radiation

ii. Cannot travel fast or through objects

iii. A sheet of paper or the body’s skin can stop it easily.

b. Beta

i. Slightly more penetrating than alpha

ii. Requires a layer of clothing to stop it

c. Gamma (x-rays)

i. Faster and stronger than alpha and beta rays

ii. Easily penetrate through the human body

iii. Require several inches of lead or concrete to prevent penetration

d. Neutron radiation

i. The fastest moving and most powerful form of radiation

ii. Neutrons easily penetrate through lead.

iii. Require several feet of concrete to stop them

C. Sources of radiologic material1. There are thousands of radioactive materials found on earth that are generally used to

benefit humankind through medicine, killing germs in food, and construction work.

a. Once it has been used for its purpose the leftover material is called radiologic waste.

i. Remains active but is no longer usefulii. Can be found at a number of locations

(a) Hospitals(b) Colleges and universities(c) Chemical and industrial sites(d) Power plants

D. Radiologic dispersal devices (RDDs)1. Any container that is designed to disperse radioactive material

a. Generally requires the use of a bomb, also known as a dirty bomb

i. Carries the potential to injure victims with both the radioactive material and the explosives used to deliver it

b. A dirty bomb’s destructive capability is limited by the explosives that are attached to it.

i. If an explosive is designed to kill 10 people it will do the same even with radioactive material added.

2. Nuclear energy

a. Artificially released by altering or splitting active atoms

i. Results in an immense amount of energy that will usually take the form of heat

b. Used in:

i. Medicine

ii. Weapons

iii. Naval vessels

iv. Power plants

c. Gives off all forms of radiation including the most deadly type, neutrons

d. When it is no longer useful it becomes waste that is still radioactive.

3. Nuclear weapons

a. Nuclear weapons are kept in a secure facility due to the destructive energy they create.

i. Terrorist groups with close ties to nations have actively attempted to build nuclear weapons.

b. After the fall of the former Soviet Union many small nuclear devices were lost.

i. Special atomic demolition munitions (SADMs) are small suitcase-sized weapons, also known as “suitcase nuke.”

ii. SADMs were designed to destroy individual targets like buildings, bridges, tunnels, or large ships.

4. How radiation affects the body

a. Effects of exposure vary depending on the amount and the route of entry.

b. There are three levels of radiation exposure.

i. Radioactive exposure

(a) Exposure to radioactive material occurred, but the body isn’t necessarily contaminated.

ii. External contamination

(a) The skin was contaminated, but the inside of the body isn’t necessarily contaminated yet.

iii. Internal contamination

(a) The inside of the body is contaminated.

c. Radiation can enter through all routes of entry as well as through the body (irradiation).

d. The radiation source will irradiate the person from within once in the body.

e. Some common signs of acute radiation sickness include:

i. Nausea

ii. Vomiting

iii. Diarrhea

5. Medical management

a. Being exposed to a radiation source does not make a patient contaminated or radioactive.

i. Contamination occurs when they have a radioactive source on their body like debris from a dirty bomb

ii. Must initially be treated by a HazMat responder before you can begin treatment with the ABCs or for burns or trauma

6. Protective measures

a. There are no suits or protective gear designed to completely shield you from radiation.

b. Use time and distance, and shield yourself in Level C protection from the source.

c. Time

i. The less time exposed the less the effects will be.

ii. If you realize the patient is near a radiation source leave it immediately

d. Distance

i. Radiation has a limit on how far it can travel.

ii. Moving a few feet can be enough to remove you from immediate danger depending on the type of radiation (inverse square law)

e. Shielding

i. A specific object can stop the path of radiation.

ii. You will never know the type of radiation that is being emitted so assume it is the strongest form.

iii. Use concrete shielding like buildings or walls between you and the incident

IX. SummaryA. You may be called to respond to a terrorist event due to the increase in terrorist

activity. Prepare yourself mentally and physically.

B. Weapons of mass destruction complicate the management of an incident. Be aware of your surroundings, and protect yourself by not coming into contact with the agent.

C. Terrorism is a violent act to intimidate or coerce a government, civilian population, or any other segment to further political or social objectives. It is in violation of United States criminal laws.

D. There are international and domestic terrorist groups categorized as violent religious groups/doomsday cults, extremist political/social groups, technology or cyberterrorists, single-issue terrorist groups, and narcoterrorists.

E. The National Terrorism Advisory System (NTAS) replaced the color-coded system with threat levels of elevated or imminent that alert responders to the

potential of an attack, specifics of the threat if known, and advises on protective levels.

F. Based on the threat level take appropriate actions and precautions. Know the policies your organization has regarding that threat level.

G. You can get clues as to whether an emergency is the result of an attack by the type of location, type of call, number of patients, patients’ statements, and preincident indicators.

H. If you suspect a terrorist or WMD event ensure the scene is safe, and do not enter if you have any doubts.

I. Notify the dispatcher and inform of the nature of the event, additional resources needed, estimated number of patients, and the upwind or optimal route of approach.

J. Establish a staging area for units to converge, keeping in mind access and exit routes.

K. Constantly assess and reassess the scene for safety; terrorists may set secondary devices off.

L. A weapon of mass destruction is any nuclear, chemical biologic, or explosive weapon or agent designed to bring mass death, casualties, or damage to property and infrastructure.

M. Explosives are the most common weapons of terrorists. Incendiary weapons involve agents and chemicals to start first. Ammonium nitrate bombs and suicide bombers are examples.

N. Chemical agents include vesicants or blister agents, respiratory or chocking agents, nerve agents, metabolic or blood agents, and irritating agents. Decontamination of a patient is always the first step. Don’t approach a patient until hazardous materials team has cleared them. Treatment includes airway management, IV access, and rapid transport.

O. Patients exposed to nerve agents can be treated with an antidote delivered as an auto-injector. Multiple doses may be needed. Follow local protocol.

P. Biologic agents include viruses such as small pox and those that cause viral hemorrhagic fevers, bacteria, and neurotoxins.

Q. Standard precautions are extremely important when treating patients exposed to biologic agents.

R. Nuclear or radiologic weapons can create massive destruction. Radioactive material may be used in a radiologic dispersal device, or dirty bomb, but the majority of damage comes from the explosives, not the radioactive material.

S. Patients who are potentially exposed to radioactive material must be decontaminated before contact. Time, distance, and shielding are the best ways to protect yourself.

Post-LectureThis section contains various student-centered end-of-chapter activities designed as enhancements to the instructor’s presentation. As time permits, these activities may be presented in class. They are also designed to be used as homework activities.

Assessment in ActionThis activity is designed to assist the student in gaining a further understanding of issues surrounding the provision of prehospital care. The activity incorporates both critical thinking and application of paramedic knowledge.

Instructor Directions1. Direct students to read the “Assessment in Action” scenario located in the Prep Kit at the

end of Chapter 50.

2. Direct students to read and individually answer the quiz questions at the end of the scenario. Allow approximately 10 minutes for this part of the activity. Facilitate a class review and dialogue of the answers, allowing students to correct responses as may be needed. Use the quiz question answers noted below to assist in building this review. Allow approximately 10 minutes for this part of the activity.

3. You may wish to ask students to complete the activity on their own and turn in their answers on a separate piece of paper.

Answers to Assessment in Action Questions1. Answer: C. Alpha

Rationale: Alpha rays are the least harmful type of penetrating radiation. Alpha rays are easily blocked by the body’s skin and do not cause internal damage. Beta rays are stronger than alpha rays and require a layer of clothing to prevent absorption. Gamma rays are faster and stronger than both alpha and beta rays. In order to prevent absorption of gamma rays, a person must be shielded by either several inches of lead or concrete.

2. Answer: B. Botulinum

Rationale: Botulinum is the most potent neurotoxin known. Once it enters the body, botulinum attacks the nervous system, leading to muscle paralysis and death. Ricin causes pulmonary edema, respiratory failure, and circulatory failure. Sarin and tabun are nerve gases that affect the body in a manner similar to organophosphates.

3. Answer: D. viral hemorrhagic fever.

Rationale: Ebola is an example of a viral hemorrhagic fever. Other examples of viral hemorrhagic fevers include Rift Valley fever and yellow fever.

4. Answer: A. Chlorine

Rationale: The pulmonary agent chlorine was the first agent ever used in warfare.

5. Answer: D. All of the above

Rationale: The anthrax bacterium lies dormant in a spore until it is exposed to the optimal temperature and moisture. When that happens, the bacterium is released from the spore and can present a threat to humans. Anthrax can enter the body in one of three ways: inhalation, cutaneous (through the skin), or gastrointestinal (ingesting contaminated food).

6. Answer: B. neurotoxins.

Rationale: The most deadly substances known to humans are neurotoxins. These substances can be made from a wide variety of sources including plants, marine animals, molds, and bacteria.

7. Answer: B. Ricin

Rationale: Ricin, one of the most potent toxins known to humans, is made from the waste material left over from processing the castor bean.

8. Answer: C. bubonic plague.

Rationale: The bubonic plague infects the lymphatic system, which in turn can affect a person’s ability to fight infection. Anthrax, as described above, is a bacteria that can attack the skin, lungs, or gastrointestinal tract, depending on its route of entry. Botulism affects the normal function of a person’s nervous system, whereas Rift Valley fever causes blood to leak out from the tissues and blood vessels.

9. Answer: D. All of the above

Rationale: Although radiologic waste continues to be radioactive, it is no longer considered useful and must be safely removed and stored. Radioactive wastes can be found at hospitals, colleges and universities, chemical and industrial sites, and power plants.

10. Answer: B. points of distribution.

Rationale: Points of distribution are strategically placed facilities that have been preestablished for the mass distribution of antibiotics, vaccinations, and other medical supplies.

Additional Questions11. Rationale: One of the primary concerns of medical personnel involved with disaster

management is how to allocate resources once they become scarce. Criteria should be established regarding who receives treatment first and who must wait. Another consideration is whether EMS providers, law enforcement officers, and other public safety personnel should be given vaccines before the general public receives them. EMS may need to consider whether resources such as mechanical ventilators be removed from patients receiving long-term ventilatory support or those with poor prognoses, to provide support for patients predicted to have better outcomes. These are all challenging ethical issues that lead to significant debates. At present, several multidisciplinary committees are working on developing guidelines for such decisions.

AssignmentsA. Review all materials from this lesson and be prepared for a lesson quiz to be

administered (date to be determined by instructor).

B. Read Chapter 51, Disaster Response, for the next class session.

Unit Assessment Keyed for Instructors 1. What is the US Department of Justice definition for terrorism?

Answer: The US Department of Justice defines terrorism as a violent act dangerous to human life, in violation of the criminal laws of the United States or any state or subdivision thereof, to intimidate or coerce a government, the civilian population, or any segment thereof, in furtherance of political or social objectives.

(p 2290)

2. How does the US Federal Bureau of Investigation define international terrorism?

Answer: The US Federal Bureau of Investigation defines two types of terrorism: international terrorism and domestic terrorism. International terrorism, also known as cross-border terrorism, is defined as acts of terror committed by foreign agents. International terrorism can be further categorized into the following subgroups: Non-state-supported terrorism, which is terrorism that is either indigenous or transnational, and that does not receive direction or support from a government. State-sponsored terrorism is terrorism that is funded or supported by a government; the government holds close ties with the terrorist group, but the terrorist group still acts independently. State-directed terrorism is terrorism directed by a government; terrorists act as direct agents of the government.

(p 2290)

3. What is meant by the term covert act?

Answer: Most acts of terror are covert, which means that the public safety community generally has no prior knowledge of the time, location, or nature of the attack. This element of surprise makes responding to an event more complex. You must constantly be aware of your surroundings and understand the possible risks for terrorism associated with certain locations, at certain times. It is therefore important that you know what locations or events in your jurisdiction would be considered high-value targets for terrorists.

(p 2293)

4. What are some of the ways to distinguish between a standard MCI and a terrorist event?

Answer: One of the easiest ways for you to distinguish between a nonterrorist multiple-casualty event and a terrorist event is that the intentional use of a WMD affects multiple persons. These casualties will generally exhibit the same signs and symptoms. It is highly unlikely for more than one person to experience a seizure at any given time. It is not uncommon to find multiple patients complaining of difficulty breathing at the scene of a fire. However, the same report in the subway at rush hour, when no smell of smoke has been reported, is certainly cause for suspicion. In these situations, you must use good judgment and resist the urge to “rush in and help,” especially when there are multiple victims from an unknown cause.

(p 2294)

5. What are some considerations for establishing a safe staging area?

Answer: It is extremely important to establish a safe staging area where other units will converge. Be mindful of access and exit routes when you direct units to respond to a location. It is unwise to have units respond to the front entrance of a hotel or apartment building that has had an explosion, because perpetrators may plant secondary devices at entrances, expecting responders to enter there.

(p 2296)

6. What is the definition of weapon of mass destruction (WMD)?

Answer: A weapon of mass destruction (WMD) is anything used as a weapon designed to bring about mass death, casualties, and/or massive damage to property and infrastructure (bridges, tunnels, airports, and seaports). WMDs can be grouped into four major categories: explosive/incendiary devices, chemical, biologic, and radiologic/nuclear weapons. These can include poison gas, grenades, rockets or missiles with a propellant charge or explosive, or a mine or similar device.

(p 2297)

7. What are the classifications of chemical agents?

Answer: These agents can be categorized as follows:

Vesicants or blister agents (eg, mustard gas and lewisite)

Respiratory or choking agents (eg, phosgene or chlorine)

Nerve agents (eg, sarin, soman, tabun, or V agent)

Metabolic or blood agents (eg, hydrogen cyanide, cyanogen chloride)

Irritating agents (eg, mace, chloropicrin, tear gas, capsicum/pepper spray, and dibenzoxazepine)

(p 2298)

8. What do the mnemonics SLUDGEM and DUMBELS stand for?

Answer: The military mnemonic SLUDGEM stands for Salivation, Lacrimation, Urination, Defecation, GI distress, Emesis, Miosis. The medical mnemonic DUMBELS stands for Defecation, Urination, Miosis, Bradycardia/Bronchorrhea, Emesis, Lacrimation, Salivation.

(p 2302)

9. What is a biological agent?

Answer: Biologic agents are organisms that cause disease or death. They are generally found in nature; for terrorist use, however, they are cultivated, synthesized, and mutated in a laboratory. The weaponization of biologic agents is performed to artificially maximize the target population’s exposure to the germ, thereby exposing the greatest number of people and achieving the desired result. The primary types of biologic agents that you may come into contact with during a biologic event include viruses, bacteria, and neurotoxins.

(p 2303)

10. How is the energy from radiation catagorized?

Answer: The energy that is emitted from a strong radiologic source is either alpha, beta, gamma (x-rays), or neutron radiation. Alpha is the least harmful penetrating type of radiation and cannot travel fast or through most objects. In fact, a sheet of paper or the body’s skin easily stops it. Beta radiation is slightly more penetrating than alpha and requires a layer of clothing to stop it. Gamma or x-rays are far faster and stronger than alpha and beta rays. These rays easily penetrate through the human body and require either several inches of lead or concrete to prevent penetration. Neutron energy is the fastest moving and most powerful form of radiation. Neutrons easily penetrate through lead and require several feet of concrete to stop them.

(p 2310)

Unit Assessment1. What is the US Department of Justice definition for terrorism?

2. How does the US Federal Bureau of Investigation define international terrorism?

3. What is meant by the term covert act?

4. What are some of the ways to distinguish between a standard MCI and a terrorist event?

5. What are some considerations for establishing a safe staging area?

6. What is the definition of weapon of mass destruction (WMD)?

7. What are the classifications of chemical agents?

8. What do the mnemonics SLUDGEM and DUMBELS stand for?

9. What is a biological agent?

10. How is the energy from radiation catagorized?