Independent research project created for Nashoba Regional High School's EMT Cadet Program, run by Bolton Ambulance Squad and Quality EMS educators.

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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. CNN Report on First Responders

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. 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. 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. 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. 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. 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. 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>.