3. 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 terrorist's creativity?
• palliative and analytical capabilities are
expensive but not necessarily effective.
4. Laboratory Nuclear
error with emission (NR)
CBR emissions
Industrial 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)
5. A CBRN attack:-
• unanticipated, unfamiliar threat to health
• lack of sensory cues
• prolonged or recurrent & long aftermath
• potentially highly contagious
• produces observable casualties.
6. 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).
7. What problems will volunteers, first
responders 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.
10. The role of scenarios in
indicating needs for preparedness
11. Aum Shinrikyo
(the "Religion of Supreme Truth")
20 March 1995 attack on
five 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.
12. Aum Shinrikyo attack (1995)
Dead: 12
Critically injured: 17
Seriously ill: 37
Moderately ill: 984
Slightly ill: 332
• 110 hospital staff and 10% of
first responders intoxicated
• "Worried well": 4,112 (85% of patients).
13. 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.
14. In the London Underground tunnels
on 7 July 2005 rescue operations
by London Fire Brigade were
delayed by 15-20 minutes by
the need to ascertain whether
CBRN contaminants had been
used in the attacks. Meanwhile,
victims died of their injuries.
15. 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"? .
17. Triage problems:-
Level 1 - on-site triage
Level 2 - medical triage
Level 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
18. 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.
19. Possible effects of chemical attack
Psychological reactions:-
• acute stress disorder
• grief
• anger and blame
• contagious somatization
...but not panic?
Physical effects:-
• cancer
• birth defects
• neurological, rheumatic,
and immunological diseases.
20. Very considerable uncertainty surrounds
the practice of decontamination,
regarding protocols, practices
effects, efficiency and timespans.
21. 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 upwind
PPE=personal protection equipment
22. 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.
23. Limitations on use of PPE:-
• restriction of physical activity
(manual dexterity, hearing)
• communication problems
• dehydration
• heat-related illness
• psychological effect
(e.g. claustrophobia).
24. 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.
25. Mythmongering:
"Problems with crowd control, rioting,
and other opportunistic crime could
be anticipated" (Staten 1997)
The assumption of panic and the
hiatus between sociological and
psychological views of the phenomenon.
26. A study by Hantsch et al.* suggested that
one 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
28. Medical personnel have the same
vulnerabilities and preoccupations as
the general public: they may need...
• emergency medical and
psychological assistance
• long-term healthcare
and health surveillance
• extensive medical information
and risk assessment.
29. 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.
30. 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.
31. Thank you for your attention!
David.Alexander@grforum.org
www.slideshare.net/dealexander
John Singer Sargent, Gassed, 1918
