EMERGENCY SERVICES
Hospital checklist Is there a hard fence surrounding the hospital?
Are all buildings’ entrances and windows on ground level secured? Is there adequate PPE for normal hospital security personnel?
Is hospital security personnel trained to operate in contaminated environments/crowd control?
Is there adequate PPE for EMS personnel? Is the EMS personnel trained to deal with contaminated mass casualties?
Is there provision for critical equipment able to operate in contaminated environment – i.e. respirators with NBC filters?
Are there fixed or deployable decontamination facilities?
Is there provision for decontamination of sensitive medical equipment? Is there a CBRN medical stockpile available – i.e. antidotes?
Are there fixed or deployable morgue facilities for contaminated victims’ corpses? Is there provision for sensitive medical data protection? Is there provision for contaminated waste management?
“It will not happen to us” But what if conventional attacks are more complicated, or combined with non- conventional means like CBRNE agents? The element of ‘unknown’ is the regulating factor in this category of disasters. We grow up together with earthquakes, fires, floods, tornadoes, even tsunamis. We experienced two world wars and nuclear catastrophes like – present to past - Fukushima, Chernobyl, Hiroshima and Nagasaki. We are familiar with conventional terrorism, suicide bombers, airplane hi-jacking to the magnitude of the 9/11 massacres, piracy, and organised crime. We fight pathogens and diseases and have managed to survive recent epidemics and new pandemics caused by the H5N1 and H1N1 viruses. Modern societies will be paralysed and
traumatised if CBRNE agents were released by terrorists. ‘Invisible’ terror - even in theory - is incapacitating in itself and cannot be easily managed or controlled. Medical/ hospital community is no exception. As normal humans both physicians and nurses are inherent believers of the lay attitude “it will not happen to us. It will not happen ever!” But life strongly suggests that even if we ‘anticipate the best’ we have to ‘prepare for the worst.’ In that respect, is the medical/ hospital community prepared to deal with mass casualties following a terrorist CBRNE attack in an urban environment? Let us analyse the main players involved in such a scenario:
Planners It is very easy to make plans. But are these plans anthropocentric and realistic? It is surprising that in many instances planners have only theoretical knowledge of the problem they are about to solve. Lacking of practical experience affects planning effectiveness greatly. For example, if a planner has never been in personal protective gear he might order first responders in ‘Level-A PPE’ to carry stretchers with victims away from the hot zone. This might be very impressive for the mass media watching but catastrophic for the mission or the first responder himself!
Yes No Yes No Yes No
Yes No Yes No
Yes No Yes No Yes No
Yes No Yes No Yes No Yes No Yes No
International cooperation during the planning phase is a logical proposal but usually rejected due to internal domestic nuisances. Plans should always address this important question: “What would I do, if I was involved in a real CBRNE incident?” Why rush to save victims in the hot zone when it is for sure that they would be either dead or about to die due to their severe wounds and/ or contamination (20%), the moment that the vast majority of the walking victims (80%) will flee to all hospitals in the city? Why not plan to fortify hospitals with ordinary and CBRN first responders instead - in order to control the end destination of all these people and avoid secondary contamination of precious premises? Not to mention the 1:5 ratio between true contaminated victims and ‘worried well’. Therefore it is important to keep plans simple, short, update, available and realistic. Interoperability and equipment compatibility at national level is mandatory and a self- explained prerequisite.
Health authorities If health authorities do not share the possibility of such a threat to become a reality then the game is over even before it starts. Positive attitude will inspire the rest of the medical chain to respond accordingly. In contrast, the ‘will-not-happen-to-us’ virus will spread with pandemic speeds and will affect the entire national health system.
Hospital personnel Hospital personnel are the most important players in this response cataract. Smart motivation is the antidote of any hesitation or reluctance to be actively involved into medical CBRNE operations. Ignorance of the threats, lack of training and the materialistic nature of men compose a very strong front of objection that might compromise any effort and sabotage
all plans. Doctors and nurses fight death on a daily basis because through their education and skills they look death in the eyes. Train and support them to deal with this invisible threat and they will accept the challenge.
Hospital infrastructure and equipment In the check list detailed in the box above, if your objective ‘No’ answers are more than the ‘Yes’ answers, then most probably you will find yourselves in trouble in case of a real event.
Ambulance service vs. NHS hospitals These two front-line organizations will bear the weight in a real event. The Ambulance Service through HART (Hazardous Area Response Teams) is well prepared to operate in a contaminated environment. They have the equipment, communications, stockpile and relevant training to reassure an effective involvement during the critical Golden Hour of the event. There is no adequate information about
the preparedness of NHS hospitals and staff suggesting that it is either a well-kept secret or proof of an existing gap. I sincerely would like to believe that this open-source ‘silence’ is part of the overall preparedness plan for the coming London Olympics.
It might happen to us as well If in January 2011 a working scenario including a mega earthquake, a mega tsunami and a mega nuclear plant meltdown were proposed, participants might consider it as science fiction or even laugh. But it happened in Japan in March 2011 and the whole world was devastated by the consequences of this catastrophic ‘sci-fi’ combination. Following this, no authority worldwide has the right to ignore the possibility of a CBRNE terrorism attack and certainly not the medical/hospital/ public health community.
“It is important to keep plans simple, short, update, available and realistic.”
48 | CHEMICAL, BIOLOGICAL & NUCLEAR WARFARE | 2012/02
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