The CBRN problem• modern society changes so fast that historical analysis may not be useful for scenario building• past events are too few and far between to help much with planning scenarios• there is an infinity of possible attack scenarios - will orthodox thinking help in the face of a terrorists creativity?• palliative and analytical capabilities are expensive but not necessarily effective.
Laboratory Nuclear error with emission (NR) CBR emissionsIndustrial Terrorist Chemical,or military attack with biological accident C, B, R or N or nuclear with CNR warfare contaminants (CBN) emissions Disease Sabotage with epidemic or poisonous agent pandemic (B)
A CBRN attack:-• unanticipated, unfamiliar threat to health• lack of sensory cues• prolonged or recurrent & long aftermath• potentially highly contagious• produces observable casualties.
What problems will volunteers, first responders and hospital staff have to deal with in a CBRN incident?• possible contamination of responders and medical staff• physical and mental state of victims and patients• uncertainty (nature of the contaminant, degree of contamination, effects).
What problems will volunteers, firstresponders and hospital staff have to deal with in a CBRN incident? • lack or inadequacy of protective equipment • lack of training and exercising (to know what to do) • lack of familiarity with equipment and procedures.
The role of scenarios inindicating needs for preparedness
Aum Shinrikyo (the "Religion of Supreme Truth")20 March 1995 attack onfive Tokyo metro trains:-• 5,510 people affected• 278 hospitals involved• 98 of them admitted 1,046 inpatients• 688 patients transported by ambulance• 4,812 made their own way to hospital.
Aum Shinrikyo attack (1995)Dead: 12Critically injured: 17Seriously ill: 37Moderately ill: 984Slightly ill: 332• 110 hospital staff and 10% of first responders intoxicated• "Worried well": 4,112 (85% of patients).
The case of Alexander Litvinenko• a small, concentrated attack with a highly toxic substance: 210Po• 30 localities contaminated• tests on hundreds of people• a strain on many different agencies• problems of determining who was responsible for costs of clean-up.
In the London Underground tunnelson 7 July 2005 rescue operationsby London Fire Brigade weredelayed by 15-20 minutes bythe need to ascertain whetherCBRN contaminants had beenused in the attacks. Meanwhile,victims died of their injuries.
Delays in responding to incidents lead to heavy criticism by the public• ascertaining level of contamination takes specialised equipment & training.• can slow down rescue in critical incidents• risk aversion may lead to failure to commit staff to rescues• long-term liability for rescuers injuries is a serious problem• is it time to rethink the "rules of engagement"? .
Triage problems:-Level 1 - on-site triageLevel 2 - medical triageLevel 3 - evacuation triage• requires specialised procedures• must avoid contamination of staff• requires ionising radiation dosimeter• biological symptoms may be delayed by 3 minutes - 3 weeks. Mettag CB-100
Contaminated patients• risks of secondary contamination of responders and hospital staff• shortage of personal protection equipment & expertise on how to use it• shortage of isolation facilities.
Possible effects of chemical attackPsychological reactions:-• acute stress disorder• grief• anger and blame• contagious somatization...but not panic?Physical effects:-• cancer• birth defects• neurological, rheumatic, and immunological diseases.
Very considerable uncertainty surrounds the practice of decontamination, regarding protocols, practices effects, efficiency and timespans.
PPE level A (contaminant unknown) Hot area PPE level B (contaminated) (contaminant known) Warm area Medical (decontamination) staff and PPE level C first responders Cold area PPE level D (clean treatment) >300 m upwindPPE=personal protection equipment
In the case of a chemical attack, the following aspects of decontamination protocols are highly debatable:• the use of chemical agents to neutralise toxic substances• whether to strip naked before treatment• what decontamination technique should be used if the toxic agent has not been identified• how many people can be decontaminated per unit time.
Limitations on use of PPE:-• restriction of physical activity (manual dexterity, hearing)• communication problems• dehydration• heat-related illness• psychological effect (e.g. claustrophobia).
Health concerns following a CBRN attack• chronic injuries and diseases directly caused by the toxic agent• questions about adverse reproductive outcomes• psychological effects (persistent)• increased levels of somatic symptoms.
Mythmongering:"Problems with crowd control, rioting, and other opportunistic crime could be anticipated" (Staten 1997) The assumption of panic and the hiatus between sociological andpsychological views of the phenomenon.
A study by Hantsch et al.* suggested thatone third or more of emergency personnel would not respond to a CBRN incident (absentee rate in natural disaster are lower than one in seven) • The greatest enemies are uncertainty and unfamiliarity • The only antidotes are information and authoritative reassurance. 2004, Annals of Emergency Medicine
Medical personnel have the samevulnerabilities and preoccupations asthe general public: they may need... • emergency medical and psychological assistance • long-term healthcare and health surveillance • extensive medical information and risk assessment.
Training needs - how to...• work in a contaminated environment• identify possibly contaminated scene• recognise symptoms of nerve agents, blister agents and asphyxiants• inform mass media about CBRN event.
We need to know how to deal with:-• "gas mania" (influx of the worried well)• a complex and unfamiliar situation• balance between action and precautions• shortage of equipment and training• the worry caused by uncertainty.
Thank you for your attention! David.Alexander@grforum.org www.slideshare.net/dealexander John Singer Sargent, Gassed, 1918