Emergency Response To Multi Casualty IncidentsPresentation Transcript
Emergency Response to Multi casualty Incidents By: Dr Ashendu Kumar Pandey Sr. Partner : EMLC, EMRI – Gujarat October 2008
July of 2008
Serial blasts rock the city of Ahmedabad
55 people dead
Diamond city -Surat : Several unexploded live bombs diffused
Many cities in India have suffered similar brunt of terrorist attacks (Hyderabad, Bangalore, Delhi and Varanasi to name a few) – Delhi being most recent
Onus on local fire and emergency service organizations to pick up the pieces.
Based on the overall government efforts to prevent and respond to terrorist incidents - Fire/Police/EMS services, collectively – have scope for better preparedness to handle such challenges & graver challenges like a chemical or biological terrorist incident .
Is a Multi Casualty incident inevitable?
A report released on the same issue by the U.S. Senate Subcommittee says that it is. The report said….
" It is not a matter of IF, but rather WHEN such an event will occur. Many of the terrorist groups of today appear more and more likely to utilize weapons of mass destruction."
Deciding the “Emergency Response” Nature of the situation qualifies the Extent and degree of the required “ Emergency Response ”
Routine - day trauma and medical situations
(Bomb Blasts, Firing, Riots, Violence in any form)
National Security Alerts
We elaborate on Emergency Response to “ Multi casualty Incidents ” in this presentation
The primary concern in potential Multi Casualty incident is to secure the area and to ascertain the severity and the nature of the threat.
Scene Safety Scene Security
… . First/Primary Concern
Delayed explosives or materials intended to harm rescue workers (e.g. Ahmedabad Civil Hospital) may have been planted at the site.
A safe scene must be obtained to avoid further endangering survivors and health care workers.
Primary and secondary perimeters must be established and secured.
It should also be determined if a cleared, downwind perimeter is needed, and one should be established if required.
Scene Safety Scene Security
… . First/Primary Concern
The Acronym “ ASBESTOS ” can be used to remember the important aspects of exposure: A - Agent(s) - Type and amount of doses
S - State - Liquid, solids, or aerosolized
B - Body sites - Areas of exposure, lungs, skin, or other
E - Effects - Area of effects; local or systemic
S - Severity, of symptoms
T - Timing of events
O - Other diagnoses to consider
S - Synergism - Interaction between multiple agents or coexisting
… . First/Primary Concern
Early involvement of support and ancillary services, mutual aid agencies, and local agencies in the planning process is prudent.
Upon identifying the potential threat, type of protective equipment is necessary to be determined.
Emphasis must be placed on protection and decontamination of rescuers and victims.
After establishing a decontamination and triage area, rescuers should put on appropriate protective clothing before entering the affected area and beginning rescue efforts.
The first focus is on supportive care with emphasis on aggressive airway control and decontamination. Issues associated with simultaneous containment, neutralization, and/or decontamination may be addressed by ancillary agencies.
Following initial triage, patients are given primary or aggressive aid depending on their presentation and the resources available.
The patients should be decontaminated and transported to a facility that has been informed about the etiology of the incident as soon as feasible. A secure and clean area completes the physical response.
Record keeping, analysis of the incident, and investigations conclude the complete response.
Priority Problem : Identification
While lacking the cachet of nuclear, biological, or chemical weapons, conventional explosives are more likely to be the instrument of a terrorist attack.
Ease of obtaining materials and knowledge make conventional explosives more likely a vehicle than other, more difficult to obtain or manufacture agents.
Historical analysis consistently demonstrates that the most likely terrorist weapon causing a mass casualty event is a standard explosive device detonated in a crowded area.
Terrorist Weapons – Explosives, Biological and Chemical Agents
A normally stable material that, when introduced into a chemical reaction, converts rapidly from a solid or a liquid to an expanding gas.
Cause damage primarily through tremendous increases in atmospheric pressure. The initial shock, called the positive pressure wave, is the almost instantaneous increase of pressure from a blast, and the negative pressure wave immediately follows, as the displaced air rushes in to fill the void caused by the initial pressure wave.
Explosives are categorized as either low grade or high grade.
Low-grade explosives burn rapidly. Black powder, the original low-grade explosive, served as the basis for the development of smokeless gunpowder and some rocket propellants. Other examples of low-grade explosives are nitro starch, nitrocellulose, and commercial fireworks.
High-grade explosives, also termed detonating explosives, are more stable than low-grade explosives, frequently requiring trauma or shock for detonation. Nitroglycerin is the original high-grade explosive. Ammonium nitrate is another example of the early types of detonating explosives. Composition B, C-3, C-4, and TNT were developed later. Other examples include Amatol 80/20, RDX, PETN, and dynamite. Initiating high-grade explosives are a separate class of very sensitive high-grade explosives, such as lead styphnate and lead azide.
. . . . Explosives
Explosions in confined spaces are often associated with much higher mortality. Solid surfaces act to reflect and compound the shock waves, causing magnification of the destructive forces. Similarly, blasts that are channeled by alleyways or hallways can have profound impact far outside the normal blast radius because the forces are focused on a smaller area of effect.
Blast injuries can often be categorized as Primary , Secondary , or Tertiary .
Primary blast damage is seen as a result of the tremendous pressure changes associated with explosives, in particular high explosives. Bowel, nervous system, cardiovascular system, ears, and lungs are most often affected by the primary blast. Cardiac contusion, esophageal rupture, hemothoraces or pneumothoraces, perforated bowel, arterial gas embolism, or immediate or delayed GI injuries should be suspected as clinically indicated. Burns are also possible, depending on the proximity to the blast.
Secondary blast injuries occur when victims are struck with shrapnel or objects sent airborne during the primary blast. Shrapnel can be the result of environmental objects as innocuous as sticks or rocks, or as malevolent as screws and nuts packed within the primary explosive.
Tertiary blast injuries occur when victims themselves are thrown due to the incredible pressures from the blast. These injuries can include a wide variety of traumatic etiologies similar to a fall of significant magnitude.
. . . . Explosives
"Suicide bombers" often carry a small amount (5-40 lb) of high explosives with an associated detonating device in a clandestine manner seeking to detonate the explosives near a large group of victims.
Typical sites include sporting events, restaurants, nightclubs, or other public functions.
Shrapnel can serve to extend the injury area, and a suspicion for projectile injuries should be maintained.
Extreme care should be exercised in approaching a potential suicide bomber, even if incapacitated.
Suspected perpetrators should be evaluated by experienced bomb squad personnel before EMS intervention to ensure a safe environment.
Were first used extensively in World War I with dramatic results against unprepared troops.
Although far less lethal than conventional explosives, chemical weapons can affect and incapacitate large numbers of troops in a short time.
Chemical warfare agents were defined by the United Nations in 1969 as "chemical substances, whether gaseous, liquid or solid, which may be employed because of their direct toxic effects on man, animals, or plants."
The ready availability of precursors of modern chemical weapons and copious documentation on their preparation make the use of chemical weapons for terrorist actions far more likely than use of nuclear or biological weapons. In addition, potential terrorists could easily locate a chemical production facility, sabotage it using chemical or conventional explosives, and allow ambient winds to spread the toxins.
The resultant environmental contamination would fulfill many terrorists' objectives of generating fear, trepidation, and panic among the population.
Chemical agents are separated into 2 broad categories: lethal and nonlethal. Lethal agents include cyanides, nerve agents, vesicants, and choking agents. Nonlethal agents include lacrimating, emesis-inducing, and incapacitating agents.
The Biological and Toxin Weapons Convention of 1972 banned the development, production, and stockpiling of biological weapons not required for peaceful intentions.
The United States, United Kingdom, Soviet Union, and 67 other nations signed this document. Despite the fact that no biological agents have been used officially in warfare to date, the prospect of their use raises many concerns.
Terrorism's history suggests the potential for the use of biological agents . Many authorities fear the use of biological agents more than the use of chemical agents because antidotes and specific countermeasures are available for some chemical weapons.
Use of biological agents in terrorist acts potentially could cause tens of thousands of casualties and cost the US economy billions of dollars.
Various scenarios involving use of biological weapons are possible, from a sudden epidemic to a sub acute, prolonged pandemic.
Pathogens might be disseminated without anyone's realizing it until after the incubation period ends, by then exposing hundreds or thousands of civilians.
Anticipating and controlling the dissemination of biological weapons may be difficult, causing complications for terrorists and intended victims. The effects of a biological agent also could evolve as a slowly developing, hard-to-categorize cluster of widely scattered cases, inadvertently allowing further dissemination of the pathogen until the connection is recognized.
Certain aspects of a disease outbreak may combine to prompt suspicion of terrorist activity, including temporal patterns of illness, selected populations of victims, clinical presentation of illness, certain strains or species of pathogens, geographic location, morbidity or mortality patterns, antimicrobial resistance patterns, residual infectivity, route of exposure, weather or climate conditions, incubation period, or concurrence with other terrorist activities.
Biological agents could prove to be a devastating vector; a release of only 30 kg of anthrax spores could cause as many as 30,000-100,000 deaths; in comparison a 1,000-kg atomic bomb would result in approximately 23,000-80,000 deaths. 2
. . . . Biological Agents
The number of potential biological agents is nearly impossible to estimate. Agents range from simple viruses to bacteria and compounds derived from vertebrate animals.
The second most pressing problem involving Weapons of Mass Destruction (WMD), and a terrorist release of a chemical or biological agent, is that of identification .
As is the case in most common industrial hazardous-materials accidents, the first priority in the management of the incident involves ascertaining the identity and physical properties of the substance that has been released.
It is only after the product identity can be ascertained that an effective outer perimeter can be established, neutralizations plans formulated, decontamination procedures entertained, emergency medical treatment plans made, and environmental preservation precautions taken.
Of most serious consideration by emergency planners is the fact that most civilian emergency service agencies, including specialized 108 services , currently do not possess the effective testing equipment to help identify sophisticated chemical or biological warfare agents that might be used in a potential terrorist attack. While they may be able to quantify those agents that have civilian counter-parts, for instance - organophosphate pesticides - there are any number of others, for which they have no testing reagents or detection meters. It is suggested that governmental funding be made available for the purchase of the necessary detection and monitoring equipment that emergency agencies will need to manage this burgeoning threat .
(Case Study; Sarin Poisoning of Subway Passengers in Tokyo, Japan, March 20, 1995 )
EMERGENCY SERVICE DUTIES AT A CHEMICAL/BIOLOGICAL WEAPONS RELEASE
The primary functions that must be performed at any toxic release remain fairly consistent. Top twenty actions that must be taken will generally involve:
1 . Incident "Size-up" and assessment 2. Scene Control/establishment of perimeter(s) 3. Product Identification / Information gathering 4. Pre-entry examination and determination/donning of appropriate protective clothing & equipment 5. Establishment of a decontamination area 6. Entry planning/preparation of equipment 7. Entry into a contaminated area and rescue of victims (as needed) 8. Containment of spill/release 9. Neutralization of spill/release 10. Decontamination of victims/patients/rescuers
. . . . EMERGENCY SERVICE DUTIES AT A CHEMICAL/BIOLOGICAL WEAPONS RELEASE
11. Triage of ill/injured 12. BLS Care 13. Hospital/expert consultation 14. ALS care/specific antidotes 15. Transport of patients to appropriate hospital 16. Post-Entry evaluation examination of rescuers/equipment 17. Complete stabilization of the incident/collection of evidence 18. Delegation of final clean up to responsible party 19. Record-keeping/after-action reporting 20. Complete analysis of actions/recommendations to action plan ( Author's Note: Several of these actions will be occurring simultaneously. They are listed in an approximate order of occurrence for the purposes of planning and coordination of activities.)
Preplanning & Multi Agency Response
Another major consideration is the need for an effective pre-planning process.
Although the site of an unexpected/intentional toxic release can't be anticipated or identified, the personnel and equipment that would be needed to respond to it can be.
Response mechanisms and interagency agreements, that may need to be implemented, must be up to date and workable.
Jurisdictional issues should be resolved before even the first two agencies arrive on the scene of this kind of incident.
It is mandatory that these plans be made and exercised prior to the onset of any emergency; this is particularly true when an incident of the magnitude of a terrorist chemical/biological attack is involved.
. . . . Preplanning & Multi Agency Response
Logically, as in any crisis, the local Police, Fire departments, and EMS agencies will be immediately responsible for an operation involving a chemical/biological release and mass casualties. But, depending on the circumstances of the incident, it may also be necessary to rapidly involve other state and central agencies.
The pre-plan and dispatch protocols should include the ability to contact the central and state disaster agencies, military units and specialized medical personnel/units. Local agencies, depending on their location, however, should be aware of the possibility that the assistance of some central agencies may not be forthcoming for as long as 24 hours, and that they should plan to manage any incident until the arrival of outside agencies. It would appear that any number of types of incidents would mandate a response of any number of federal agencies (i.e., terrorism, an attack on dignitaries, foreign embassies, airports, military installations, and government buildings) and consideration must be given to the fact that central law enforcement agencies will assume jurisdiction and the leadership role.
Conversely, law enforcement personnel, who may have assumed command of an incident involving a chemical/biological attack, must be cognizant of the fact that if any possible perpetrators have fled and the scene is secure, and there are still victims or a gas plume present, that a majority of the remainder of the operation will functionally and legally be the responsibility of Fire/EMS command personnel and subsequently responding central or military personnel. Obviously, excellent interagency cooperation and communication is a necessity in consequence management of chemical/bio attacks.
Intelligence & Information Sharing
One of the present problems concerning the response to chemical/biological agents is the fact that very little information sharing is taking place between differing agencies, except on an informal or individual basis.
Secondarily, there is no national "clearing house" or database of exercises that have been conducted, "lessons learned," outcomes of actual incidents, or model programs to emulate in planning efforts. It is highly recommended that a national central repository be designated and funding provided for its operation.
In the absence of such a designated center, the Emergency Management & Research Institute (EMRI) can act as an informal (and self-funded) "go-between".
More importantly, there is little sharing of intelligence information between local, state, and central agencies in regard to threats of chemical or biological attacks, real or imagined.
Rumors, misinformation, innuendo, and "just plain mistakes" abound. Often overlooked intelligence-gathering resources are available and unused within the civilian response community. Far greater strides should be made in regard to developing viable channels of communications that would transfer applicable information to and from "the street."
Emergency planners should be aware that the release of any CW/BW agent is likely to induce a psychological reaction on the part of a largely unprotected civilian population, and that problems with crowd control,
Rioting, and other opportunistic crime could be anticipated.
The primary counter to these effects must involve an effective “Psy-ops" operation to include extensive participation by public information/affairs officers and the media.
Extensive attempts must be made to prevent a "panic reaction" among those that might potentially be exposed to a warfare agent.
It is anticipated that early interventions/statements by technical experts and political leaders can help to defuse public feelings of confusion and fear...and lead citizens to appropriate behaviors.
Responding to a terrorist event can represent a considerable drain on resources for all agencies involved.
The potential for death and destruction is tremendous.
Agencies responsible for responding to terrorist events can only ensure that appropriate preparations are in place should unforeseen circumstances arise.
Extensive preplanning and interagency cooperation is essential in mitigating the effects of terrorist attacks.
A prepared and determined populace makes a less inviting target for potential terrorists.
EMRI can evolve as a “Centre of Intellectual Excellence” for information on best practices in Emergency response to terrorist attacks