1. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ CHAPTER 36 Terrorism and EMS

2. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Terrorism K ey Term A violent act dangerous to human life, to intimidate or coerce a government, the civilian population, or any segment thereof, in furtherance of political or social objectives

3. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Domestic Terrorism Directed at government or a population, without foreign direction Often fragmented and leaderless

4. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Domestic Terrorism

5. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ International Terrorism Foreign based Activities cross national boundaries Often religious or politically motivated

6. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Types of Terrorism Armed attacks Chemical Biological Radiological Nuclear Explosive Weapons of Mass Destruction

7. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ September 11, 2001

8. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Safety Always remember that responders may be targets of terrorism. Never compromise your own safety during an incident.

9. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Responder Safety Responders may be targets. Consider the possibility of secondary devices/events. Utilize SOPs & protocols. Never compromise your own safety.

10. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Responder Considerations Identifying the possible threats posed by the event Recognizing the possible harms posed by the event Identifying protection measures based on the possible threats and harms

11. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Identify Threat Posed by the Event Occupancy/Location Type of Event Timing of Event On-Scene Warning Signs “OTTO”

12. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Occupancy/Location Symbolic/Historic Targets White House IRS offices Public buildings & assembly areas Shopping malls Convention centers

13. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Occupancy/Location Controversial businesses Nuclear facilities Family planning offices Infrastructure systems Power plants Hospitals

14. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Type of Event Explosions/incendiaries Incidents involving firearms Non-trauma MCIs

15. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Timing of Event National holidays Anniversaries of other terrorist events

16. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ On-Scene Warning Signs Unexplained patterns of illness Chemical containers Unusual items at locations Fires of unusual behavior

17. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Recognize the Harms Posed by the Threat Thermal Harm Extreme heat or cold Radiological Harm Nuclear particles “TRACEM-P” Continued…

18. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Recognize the Harms Posed by the Threat.

19. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Recognize the Harms Posed by the Threat Asphyxiation Lack of oxygen in environment Chemical Harm Toxic or corrosive materials “TRACEM-P” Continued…

20. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Recognize the Harms Posed by the Threat Etiological Harm Disease causing organisms Mechanical Harm Physical trauma “TRACEM-P” Continued…

21. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Recognize the Harms Posed by the Threat Psychological Harm Creation of fear and panic “TRACEM-P”

22. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Possible Protection Measures Time Distance Shielding

23. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Responses to Chemical Incidents Hazardous Materials Industrial Waste Warfare Agents Inhaled Ingested Absorbed Injected That may be:

24. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Specific Types of Harm from Chemical Incidents Thermal Flammability/heat from reactions Asphyxiation Reactions that displace oxygen Chemical Systemic to cardiac, nervous, & respiratory systems

25. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Specific Types of Harm from Chemical Incidents Mechanical Corrosives weaken structures Psychological Emotional reaction to exposure

26. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Self Protection at Chemical Incidents Be cautious of secondary devices. Ensure victims are not the bomber.

27. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Responses to Biological Incidents May be a focused emergency or a public health emergency. Focused emergencies have a point of origin, minimizing spread. Continued…

28. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Responses to Biological Incidents Public health emergencies have a sudden demand on public health with no apparent explanation.

29. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Causative Agents of Biological Incidents Bacteria Viruses Toxins

30. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Exposure The dose or concentration multiplied by time (duration of exposure).

31. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Four Biological Agent Routes of Entry 1. Absorption Skin contact 2. Ingestion Through mouth

32. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Four Biological Agent Routes of Entry 3. Injection Needles or projectiles 4. Inhalation By breathing

33. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Contamination K ey Term Contact with or presence of a contaminant, which is material that is present where it does not belong and that is somehow harmful to persons, animals, or the environment

34. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Exposure vs. Contamination Contamination Substance clings to body or clothing. Exposure Substance enters body through one of the routes of exposure.

35. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Specific Types of Harm from Biological Incidents Etiological Poisonous hazardous materials Chemical Secondary events

36. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Specific Types of Harm from Biological Incidents Mechanical Secondary events Psychological Emotional reaction to exposure

37. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Self-Protection at Biological Incidents Use personal protective equipment. Limit exposure time. Use buddy system/RIT team.

38. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Responses to Radiological Incidents Unlikely to occur May be in the form of an explosive device Difficult to initially detect

39. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Specific Types of Harm from Radiological Incidents Thermal Nuclear explosion Radiological Ongoing, varies with substance Chemical Many substances are also chemical hazards Continued…

40. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Specific Types of Harm from Radiological Incidents Mechanical Nuclear explosion Psychological Emotional reaction to exposure

41. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Self-Protection at Radiological Incidents Use time/distance/shielding. Use decontamination procedures.

42. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Responses to Explosive Incidents Vary in size from pipe bomb to car bombs May have suicide bombers May contain chemical or biological agents Most frequent weapon used by terrorists

43. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Specific Types of Harm from Explosive Incidents Thermal Heat from detonation Asphyxiation Dusty conditions Chemical & Radiological If present in the device Continued…

44. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Specific Types of Harm from Explosive Incidents Mechanical Shockwaves and fragmentation Etiological If biological agents present Psychological Stunned response

45. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Self-Protection at Explosive Incidents Be cautious of secondary devices. Ensure victims are not the bomber.

46. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Methods of Dissemination of Agents Respiratory/Inhalation Most effective method Ingestion Effectiveness Continued…

47. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Methods of Dissemination of Agents Dermal Some agents effective this way, others prevented by logistics/ immunization

48. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Weaponization Use of sprayers to disseminate Use of explosives to disseminate

49. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Dissemination of Agents

50. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Chemical Agent Considerations Physical Considerations Extremely varied Must be gaseous, liquid, or solid Volatility May evaporate quickly

51. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Chemical Agent Considerations Chemical Reactivity & stability vary Toxicological Variety of factors influence sensitivity

52. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Classification of Chemical Agents Choking agents Vessicating agents (blister agents) Cyanides Nerve agents Riot control agents

53. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Classification of Biological Agents Bacterium Can live outside host cell Virus Cannot survive outside of host cell Toxin Poisonous chemical compound

54. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Biological Agent Weapon Considerations Infectivity Virulence Toxicity Incubation period Continued…

55. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Biological Agent Weapon Considerations Transmissibility Lethality Stability

56. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Classification of Biological Agents Infectivity Ease in invading host cell Virulence Severity of disease produced Toxicity Severity of illness from toxin Continued…

57. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Classification of Biological Agents Incubation period Time between exposure & symptoms Transmissibility Ease of passing fromperson to person Continued…

58. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Classification of Biological Agents Lethality Ease in causing death Stability Viability to outside influences

59. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Biological Weapons Bacteria Single cells, require a host. Easy to grow and spread. Anthrax Naturally occurring. Inhalation is greatest concern. Early treatment with antibiotics is key. Continued…

60. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Biological Weapons Cholera Diarrheal disease. Treat dehydration. Plague Transmitted by fleas. Can be highly contagious. Use respiratory precautions. Continued…

61. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Biological Weapons Q fever Similar to anthrax. Treat with antibiotics. Tularemia Usually from bites of animals. Fever, headache, weight loss. Treat with antibiotics.

62. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Toxin Weapons Do not aerosolize on their own Do not reproduce Do not transmit person to person Generally, intact skin is an effective barrier. Continued…

63. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Toxin Weapons Botulism One of the deadliest compounds Ricin Easy to make, common weapon Interrupts cell processes; causes death Most effective through inhalation

64. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Biological Weapons Staphylococcal Enterotoxin B (SEB) Similar to food poisoning Treatment is supportive Trichothecene Mycotoxins (T2) Death within 12 hours No vaccine Treat symptoms

65. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Virus Weapons Simplest microorganisms Require a host cell Not easy to manufacture Continued…

66. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Virus Weapons Smallpox Thought to be eradicated, but may exist Highly contagious Spread by respiratory droplets Encephalitis Naturally occurring Inflammation of the brain More incapacitating than lethal Continued…

67. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Virus Weapons Viral Hemorrhagic Fever (VHFs) Ebola, Dengue Fever, Yellow Fever Changes the clotting ability of blood Highly contagious & lethal Liquefies internal organs No vaccines or cures

68. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Radioactive / Nuclear Weapons Military / Sabotage Highly unlikely Improvised Easy to gather knowledge, implementation very difficult “Dirty Bomb” Similar issues as improvised device

69. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Incendiary Weapons More plausible by using: Molotov cocktails Propane bombs Shaped charges May disseminate other weapons

70. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Strategy and Tactics Strategies are broad plans; tactics are specific methods to achieve them. Isolation Notification Identification Protection

71. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Isolation – Initial Considerations Determine severity of danger. Control the scene & size it up. Isolate the hazard area. Attempt to evacuate (based on hazards). Establish perimeter control.

72. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Isolation – Perimeter Control May be difficult based on resources. Overestimate the size of the perimeter. Continued…

73. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Isolation – Perimeter Control Outer perimeter Most distant boundary line Restrict all public access beyond it Inner perimeter Isolates known hazards inside the outer perimeter

74. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Perimeter Control Factors Availability of resources Size & configuration of incident Stability of the incident

75. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Notification Notify federal & state support agencies during a suspected or known terrorist event (usually done by dispatch centers).

76. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Identification May or may not be possible. Do not endanger self to determine. Report obvious signs or indicators. Note placards and labels. Use the Emergency Response Guidebook. Report unusual patterns of illness.

77. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Protection EMTs are responsible to protect themselves and their equipment. Perform an initial scene survey. Request security police/military). Establish vehicle staging and treatment areas. Advise EMS command of concerns, suspicious people, and/or activities.

78. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ 1. List and briefly describe the five most common types of terrorism incidents. 2. What is a secondary device? What precautions should be taken by an EMT regarding secondary devices? Review Questions

79. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ 3. List several types of events that should trigger an EMT’s suspicion of possible terrorism involvement. 4. List the seven types of harm that result from a terrorism incident – and the seven letter acronym for these types of harm. Review Questions

80. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ. 5. Briefly discuss the concepts of time, distance, and shielding. 6. Discuss several self-protection measures for biological incidents. 7. Discuss the tactics for isolation, notification, identification, and protection. Review Questions

81. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ What are the indicators that this is a suspicious incident? What steps should be taken to isolate the area? S TREET S CENES

82. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ What steps should be taken to identify a possible mechanism of injury? Identify the critical personal protection issues on this scene. S TREET S CENES

83. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ What are the indicators that this is a suspicious incident? What protection precautions should be initiated? S TREET S CENES

84. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Discuss the proper notification procedures. What support agencies are required on this scene? S TREET S CENES