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December 20, 2002
Oh Great!  Now what do I do? 
By Captain Philip H. East, NREMT-P

That’s what you’re probably saying to yourself as you pull up to your ordinary, run of the mill, medic-assist call, to the local movie theater, for a person having a seizure.  The problem is the dispatcher told you that you were responding to ONE person having a seizure, not TWENTY! 

As most of us have been inundated with “Terrorism” training since 9/11 occurred, many of you might have a general idea of what to do, but do you have policies in place?  Does your locality have a terrorism annex to it’s Emergency Operations Plan (EOP).  Do you have an EOP?  Do you have a Mass Casualty Incident (MCI) Plan?  How many patients can your local Emergency Departments handle?  Can they decontaminate patients that self-refer to the hospital, or will you have another incident at the hospital?  All of these are questions that hopefully you are asking yourself before you get the “Seizure” call noted above.

Many localities are asking themselves these very questions while you read this, mine included.  We have a lot of them answered in my city, but it seems the more we answer, the more that come up.  So where do you start?  Well, what we chose to do in my department was to start with training.  A basic awareness of WMD hazards is the key to firefighter/EMS/police survival for these incidents.  The main principle that I can offer is… You can’t help others if you become a casualty yourself.  As in Haz-Mat incidents, if you can’t identify what you’re dealing with, stay out of it! 

The four steps my department chose to stress for the initial response to a WMD incident are:
1. Isolate the area.
2. Deny Entry.
3. Deny Exit, as much as possible.
4. Don’t let the incident get any bigger than it already is!

First, you want to Isolate the area.  That’s much easier to say than it is to ccomplish.  How far away do you set up perimeters?  How close is too close?  How far has the product spread already?  For this, use your best judgment.  If you have Haz-Mat detection and monitoring equipment available, you’re ahead of the curve.  If not, you do have some tools at your disposal already.  Think back to Haz-Mat Awareness.  The 2000 North American Emergency Response Guidebook has Chemical Weapons identified in it, and gives information on Isolation and Evacuation.  It also has explosives listed as well.  For biological incidents, most often there will be no “Scene” to respond to, as it will most likely be a public health emergency.   Should an agent be found at a scene, then the product should be treated exactly as it is, an unknown biological pathogen, and appropriate Body Substance Isolation (BSI) precautions should be taken.

Second, deny entry into the contaminated area.  That means the 1st responders also.  The only exception is when you have live victims in the hostile environment, and you can CONFIRM that they are alive from outside the environment.  Here most of you are going to say: But I don’t have Haz-Mat Suits or Haz-Mat Entry Training.  I agree completely, but we are firefighters, and that’s what we do.  As in the words of Phoenix, Arizona Fire Chief Alan Brunacini: “We risk a lot to save a savable life.  We risk a little to save salvageable property. And we should risk nothing when there are no lives or property to be saved”.  If you do have savable lives in the environment, read moving around after being exposed for 15 minutes or more.  Structural Firefighter Protective Clothing offers a certain degree of protection from some chemical weapon agents for a period of 30 minutes.  For further info please refer to the 3/30 rule from the Soldier Biological Chemical Command in Edgewood Maryland. If you have Chemical Protective Clothing (CPC) and are part of a Haz-Mat team, follow your protocols for entry into an unknown product as per your department’s policies and procedures.

Third, deny exit from the contaminated area.  Casualties leaving the area will carry the product with them on their clothing, thus expanding the hazard (Hot) zone, not to mention that they will likely contaminate your unprotected personnel (EMS and POLICE without PPE) as they leave.  They also will create new hot zones once they arrive at their destination. This will probably mean that you now have a contaminated hospital emergency department, which in turn means you have one less location to transport your patients.

And lastly, Don’t let the incident get any bigger than it already is!  If you can complete items 1 through 3 quickly, you may be able to keep the cats in a herd.  When setting up your perimeters remember to start big, and then work in. Once you have set an inner perimeter or hot zone, to make it larger becomes a monumental task.  If it was too small, your personnel will have set up apparatus to be contaminated, not to mention the personnel becoming potentially contaminated themselves.  As we learned in the Tokyo Subway Sarin Attack in 1995, conservatively 40-60%, of the casualties will have left the scene before you get there anyway.  A high priority should be to notify your local medical facilities as quickly as possible.  Advise them to be prepared to receive self-referred patients that are contaminated.  Hopefully they have decontamination equipment on-site.

These are by no means the end-all, be-all of what to do initially for a WMD/Terrorism response, but hopefully they might get you started on the way to the safe resolution of a bad situation.  Next time we’ll talk a bit about decon.

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