EMS Responce to Terrorism


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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 Responce to Terrorism

  1. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 17. CNN Report on First Responders
  18. 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. 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. 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. 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. 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. 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. 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>.