1

The ABCs of Disaster Medical Response

Manual for Providers
2nd Edition

Susan M. Briggs, MD, MPH, FACS, Editor Michael Cronin, MPH, Associate Editor

The ABCs of Disaster Medical Response

The ABCs of Disaster Medical Response

Manual for Providers 2nd Edition

Director, International Trauma and Disaster Institute, Massachusetts General Hospital Associate Professor of Surgery, Harvard Medical School

Editor Susan M. Briggs, MD, MPH, FACS

Senior Editor, International Trauma and Disaster Institute, Massachusetts General Hospital

Associate Editor Michael Cronin, MPH

The ABCs of Disaster Medical Response

This manual was made possible through an educational grant from Z-Medica and On Site Gas Systems.

Copyright 2006 , International Trauma and Disaster Institute, All rights reserved. All photos in this publication are courtesy of the authors unless otherwise noted.

Table of Contents
Introduction .....................................................................1 Chapter 1: Mass Casualty Incident Management ...................2 Chapter 2: Incident Command System ................................4 Chapter 3: Medical Response to Disasters............................6 Search and Rescue..........................................6 Triage............................................................7 Definitive Medical Care ....................................9 Evacuation ................................................... 10 Chapter 4: Chapter 5: Public Health Response to Disasters ................ 12 The Threat of Terrorism and Weapons of Mass Destruction .................................................. 14 Blast Injuries................................................ 16 Crush Injuries .............................................. 18 Biological Agents .......................................... 22 Chemical Agents ........................................... 26 Radioactive Agents........................................ 30 Chapter 6: Chapter 7: Decontamination........................................... 34 Psychological Response to Disasters ................ 36

The ABCs of Disaster Medical Response

INTRODUCTION

isasters follow no rules. No one can predict the complexity, time, or location of the next disaster. Traditionally, medical providers have held the erroneous belief that all disasters are different, especially those involving terrorism. All disasters, regardless of etiology, have similar medical and public health consequences. Disasters differ in the degree to which these consequences occur and the degree to which they disrupt the medical and public health infrastructure of the disaster scene. The key principle of disaster medical care is to do the greatest good for the greatest number of patients, while the objective of conventional medical care is to do the greatest good for the individual patient. Natural disasters, man-made disasters and terrorism encompass the spectrum of possible disaster threats. Terrorism, not surprisingly, is the most challenging for medical providers. Weapons of mass destruction creating contaminated environments will be the greatest challenge of all. A consistent approach to disasters, based on an understanding of their common features and the response expertise they require, is becoming the accepted practice throughout the world. This strategy is called the Mass Casualty Incident (MCI) Response. MCI response has the primary objective of reducing the morbidity (injury/disease) and mortality (death) associated with the disaster. All medical responders need to incorporate the key principles of the MCI response in their training given the complexity of todays disasters.

The ABCs of Disaster Medical Response

CHAPTER 1: Mass Casualty Incident Management

ass casualty incidents (MCIs) are events that cause casualties large enough to overwhelm the medical and public health services of the affected community. The severity and diversity of injuries, in addition to the number of victims, will be major factors in determining whether a mass casualty incident requires resources from outside of the community. Todays complex disasters, especially those disasters involving terrorism and weapons of mass destruction (chemical, biological, or nuclear), may result in an austere environment. An austere environment is a setting where resources, transportation, and other aspects of the physical, political, social, or economic environments impose severe constraints on the availability and adequacy of immediate care for the population in need. Similar to the ABCs of trauma care, disaster response includes basic medical and public health concerns that are similar in all disasters. The difference is the degree to which these responses are utilized in a specific disaster, and the degree to which outside assistance is needed to perform the ABCs of disaster care. Medical concerns related to MCIs include four elements:

Search and rescue Triage and initial stabilization Definitive medical care Evacuation

Chapter 1: Mass Casualty Incident Management

Public health concerns related to MCIs include:

Water Food Shelter Sanitation Safety and Security Transportation Communication Disease surveillance Endemic and epidemic diseases

Both medical and public health disaster response activities are coordinated through one organizational structure, the Incident Command System.

Ground Zero, World Trade Center, New York (2001)

The ABCs of Disaster Medical Response

CHAPTER 2:

Incident Command System

any different organizations participate in the response to a disaster. The Incident Command System (ICS) was created to allow different kinds of agencies (fire, police, emergency medical services), and/or multiple jurisdictions of similar agencies to work together effectively in response to a disaster. The ICS uses a common organizational structure and language to achieve this goal. ICS Structure and Hierarchy The organizational structure of ICS is built around five major management activities. Note: Not all activities are used for every disaster. Incident command Operations Planning Logistics Financial/Administrative FUNCTIONAL REQUIREMENTS, NOT TITLES, DETERMINE ICS HIERARCHY.

Incident Commander (IC) Maintains overall responsibility for disaster response Public Information Officer (PIO) Communicates with press and public Liaison Officer Coordinates the efforts of all responding agencies

Safety Officer Responsible for safety of responders

Operations

Planning

Logistics

Finance

Chapter 2: Incident Command System

Important Principles
1. An important part of disaster planning is the identification of the incident commander and other key positions BEFORE a disaster occurs. 2. ICS must be started early, before an incident gets out of control. 3. Medical and public health responders, often used to working independently, must adhere to the structure of the ICS in order to avoid potentially negative consequences, including:

Death of personnel due to lack of training Lack of adequate supplies to provide care Staff working beyond their training or certification

4. The structure of the ICS is the same regardless of the nature of the disaster. The only difference is in the particular experience of key personnel and the extent of the ICS utilized in a particular disaster. For example, the safety officer varies by the type of disaster:

Biological incident = Infection control expert Chemical incident = Hazardous material expert Radiation incident = Radiation detection expert.

ICS allows the integration of local EMS, fire, and police assets

The ABCs of Disaster Medical Response

CHAPTER 3: Medical Response to Disasters

1. SEARCH AND RESCUE

he local population near any disaster site is the immediate search-and-rescue resource. Many countries have developed specialized search-and-rescue teams as an integral part of their national disaster plans. Members of these teams receive specialized training in confined space environments. Search-and-rescue units generally include: A cadre of medical specialists Technical specialists knowledgeable in hazardous materials, structural engineering, heavy equipment operation, and technical search-and-rescue methods, e.g., listening equipment, remote cameras Trained canines and their handlers

Field Tip
Local construction companies may be valuable search and rescue assets by providing equipment, tools, and even wooden planks that can be used as stretchers at the disaster site.

Local residents search earthquake ruins for survivors, Bam, Iran (2003)

Chapter 3: Medical Response to Disasters

Casualty Collection Site

Casualty collection sites for Level 1 and 2 triage should be located close enough to the disaster site to offer rapid treatment but far enough away to be safe. Important features are:

Proximity to the disaster site Safety from hazards and upwind location from contaminated environments Protection from climatic conditions Easy visibility for disaster victims Convenient exit routes for air and land evacuation

2. TRIAGE
Triage is the most important mission of any disaster medical response, regardless of the nature of the mass casualty incident. The objective of conventional triage is to do the greatest good for the individual patient. The objective of disaster triage (field triage) is to do the greatest good for the greatest number of people. Field medical triage must be conducted at three levels:

On-site Triage (Level 1) Medical Triage (Level 2) Evacuation Triage (Level 3)

Color coding used at casualty collection site

Rapid categorization of victims with potentially severe injuries needing immediate medical care where they are lying or at a triage site Personnel are typically first responders from the local population or local emergency medical personnel Patients characterized as acute or non-acute Simplified color coding may be done if resources permit:

On-Site Triage (Level 1)

ACUTE = RED

NON-ACUTE = GREEN

The ABCs of Disaster Medical Response

Medical Triage (Level 2)

Rapid categorization of victims at a casualty site by the most experienced medical personnel available to identify the level of medical care needed The greatest good for the greatest number of people Knowledge of the medical consequences of various injuries (e.g., burn, blast, or crush injuries or exposure to chemical, biological, or nuclear weapons) is critical Color coding may be used:
RED

URGENT

Casualties who require immediate lifesaving interventions (airway, breathing, circulation) Casualties who do not require immediate life-saving interventions and for whom treatment can be delayed Casualties who are not expected to survive due to the severity of injuries complicated by the conditions and lack of resources Individuals who require minimal or no medical care

DELAYED
YELLOW

or EXPECTANT

GREEN

MINOR

BLACK

DECEASED

Evacuation Triage (Level 3)

Level 3 triage assigns priorities to disaster victims for transfer to medical facilities Goal is appropriate evacuation (by land or air) of victims according to severity of injury and available resources Same medical personnel as in Level 2 triage.

Chapter 3: Medical Response to Disasters

3. DEFINITIVE MEDICAL CARE

Definitive medical care generally refers to care that will improve, rather than simply stabilize, a casualtys condition, e.g., surgery or other care provided in a hospital. Requirements for definitive medical care will vary widely depending on the magnitude and epidemiology of the disaster. In some disasters, local hospitals may be destroyed, transportation to medical facilities might not be feasible, or the environment may be contaminated. In these situations, definitive care must be provided outside traditional medical facilities. Hospital teams with mobile equipment that can provide a graded, flexible response to the need for definitive medical care in disasters are key to a successful disaster response.

Definitive medical care in field tents, El Salvador earthquake (1987)

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The ABCs of Disaster Medical Response

4. EVACUATION
Evacuation can be useful in a disaster. There are several indications for evacuation in a disaster:

To decompress the disaster area To improve care for most critical casualties by removal to off-site medical facilities To provide specialized care for specific casualties, such as those with burns and crush injuries

There are also several reasons to delay or defer evacuation of some casualties. These include:

Contaminated casualties Casualties with transmissible diseases Unstable casualties

Modes of evacuation include:

Ground transport Transport by helicopters or small fixed wing aircraft Transport by large fixed wing aircraft

Patient Stresses of Flight

Hypobaric environment. At altitude, cabin pressure decreases and gas trapped in organs expands, possibly causing pneumothorax, ileus, etc. Decreased partial pressure of oxygen. Casualties with impaired gas exchange will usually experience hypoxia. Turbulence and Vibration. Patients with unstable fractures, especially spinal, are at greatest risk. Medical equipment can shift in flight or during take off and landing. Temperature and Humidity. Varying temperatures and low humidity are the norm. Monitor patients temperatures and use humidified O2 whenever possible.

Chapter 3: Medical Response to Disasters

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Interior of a military transport plane converted for medical evacuation, El Salvador earthquake (1987)

Orange crate doubles as a pediatric evacuation stretcher, El Salvador earthquake (1987)

Helicopter used for evacuation after hurricane in St. Thomas, V.I. (1991)

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The ABCs of Disaster Medical Response

CHAPTER 4: Public Health Response to Disasters

edical providers must understand the impact of disasters on the public health infrastructure in order to have an efficient medical response. The challenges related to this task are twofold:

The needs assessment must be performed concurrently with the provision of medical services. Planning the response will be based, of necessity, on limited assessment information.

The Rapid Needs Assessment provides a timely evaluation of the impact of the disaster on the affected population. The three specific elements of the Rapid Needs Assessment are described below.

1. ASSESSING THE MAGNITUDE OF A DISASTER

Media reports can provide valuable information regarding the magnitude of a disaster, particularly in the area of greatest impact. The ability of reporters to gain firsthand observational information through helicopter and fixed wing aircraft reconnaissance can provide visual information that can be used to estimate damage caused by the disaster.

Aerial reconnaissance over areas devastated by Supertyphoon Pongsona in Guam (2002)

Chapter 4: Public Health Response to Disasters

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2. ASSESSING LIFELINE SERVICES

Determining the disruption of lifeline services, including potable water supply, sanitation capacity, food supply, shelter, and electricity is critical to the relief effort. Any disruption of the communitys medical infrastructure should be examined as well.

Water

Lifeline Services: Minimum Requirements

Potable: 20 L/day/person (Increase by 20% for increased temperature or physical exertion) Sanitation: 5 L/day/person Adult: 1,900 kcal/person/day (Increase by 500 kcal/day for pregnant/lactating females) Children: varies by age

Food

Emergency/Temporary Shelter 3.5 m2/person 3. ASSESSING THE LOCAL RESPONSE

Cardinal questions in assessing local response are: 1. Are there current or future infrastructure problems?

Health and medical issues:

immediate life-threatening injury/illness epidemic and endemic diseases disrupted/overwhelmed services

Potable water: quality and quantity Food: quality and quantity Shelter Sanitation

2. Is the local community able to respond? 3. Is outside assistance needed? 4. Is the appropriate assistance being provided?

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The ABCs of Disaster Medical Response

CHAPTER 5:

The Threat of Terrorism

errorism is the most challenging mass casualty incident for emergency responders. The spectrum of terrorist threats is limitless, ranging from suicide bombers, conventional explosives, and military weapons to weapons of mass destruction (nuclear, biological, or chemical). Terrorist events have the greatest potential of all man-made disasters to generate large numbers of casualties and fatalities. Terrorists are not limited by conventional technology or weaponry. In the World Trade Center bombings on September 11, 2001, terrorists used fully fueled jumbo jets as flying bombs, generating massive destruction of life and property. One of the unique features of a terrorist threat, especially involving weapons of mass destruction, is that psychogenic casualties usually predominate. Terrorists do not have to kill people to achieve their goals: they just have to create a climate of fear and panic to overwhelm the medical infrastructure. In the March 1995 sarin attacks in Tokyo, 5,000 casualties were referred to hospitals. Of these, fewer than 1,000 were suffering from the physical effects of the sarin gas with the remaining suffering psychological stress. The recent anthrax incidents in the United States also dramatically increased the number of individuals presenting to emergency departments with non-specific respiratory symptoms. Weapons of mass destruction creating contaminated environments are the greatest disaster challenge of all. No longer will emergency responders be able to bring victims into hospitals for fear of contaminating medical facilities. Medical responders must be equipped to provide triage and initial stabilization, and possibly definitive care, at staging areas outside traditional hospital facilities.

Chapter 5: The Threat of Terrorism

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New York, World Trade Center attack (2001)

EMS providers at the scene of a suicide bombing

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The ABCs of Disaster Medical Response

1. BLAST INJURIES
Explosions and bombings related to terrorism continue to be a frequent cause of mass casualties in disasters. The majority of terrorist bombings consist of relatively small explosives that produce low casualty rates. However, when strategically placed in buildings, pipelines, or moving vehicles, their impact can be much greater. Terrorists have also begun to use larger devices that traditionally have been confined to military operations. The high morbidity and mortality is related not only to the intensity of the blast, but to the subsequent structural damage that leads to collapse of buildings, a common phenomenon in large explosions. Injuries caused by explosives and bombings can be divided into four categories: primary blast injury, secondary blast injury, tertiary blast injury, and miscellaneous injuries. Casualties often sustain mixed types of injuries.

PRIMARY BLAST INJURY (PBI)

Blasts produce a pressure wave that moves out from the center of the explosion at supersonic speed. Primary blast injury is due solely to the direct effect of the pressure wave on the body. The magnitude of the wave depends on the size of the explosion and the environment in which it occurs: the more powerful the blast, the greater the damage. The effects of the blast wave are increased in a closed space such as a building or bus and underwater. Primary blast injury occurs almost exclusively in gas-containing organs: the ear, the respiratory tract, and the GI tract.

Treatment Alert!
Tympanic membrane (eardrum) rupture is a useful marker for significant PBI. Casualties with a mechanism of injury that suggests blast injury should be observed for 12-24 hours.

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SECONDARY BLAST INJURY

Secondary blast injury is the most common cause of death in blast casualties. It is caused by flying debris, metal and glass. Traumatic amputations, fractures and soft tissue injuries are common.

Secondary blast injury from land mine

TERTIARY BLAST INJURY

Tertiary blast injury is caused by propulsion of the body by the shock wave into solid objects. Head, spine and extremity injuries are common.

MISCELLANEOUS BLAST INJURIES

Exposure to the intense heat generated by the blast can cause thermal and inhalation burns. Structural collapse can cause crush injury with secondary complications such as crush syndrome and compartment syndrome.

Summary: Mechanism of Blast Injuries CATEGORY

Primary Blast Injury Secondary Blast Injury Tertiary Blast Injury Miscellaneous Injuries

M ECHANISM OF I NJURY
Blast Wave Victim struck by flying debris Victim impacted against stationary object Burns, inhalation injuries, crush injuries

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The ABCs of Disaster Medical Response

2. CRUSH INJURY AND CRUSH SYNDROME

Crush Injury is defined as compression of extremities and body parts that causes muscle swelling and/or neurological disturbances in the affected parts of the body. Typically affected body parts include lower extremities (74%), upper extremities (10%), and trunk (9%). Non-compressible hemorrhage in crush injured extremities continues to be a major source of mortality and morbidity. In addition to standard therapeutic modalities such as gauze dressings and tourniquets, new hemostatic products, such as QuikClot powder (QC), the HemCon Bandage, and fibrin sealant dressing (FSD) are being field tested in disaster situations.

QuikClot, one example of a hemostatic agent

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Clotting agent (QC) used to stop bleeding in a wounded soldier

Crush Syndrome is localized crush injury with systemic manifestations. These systemic effects are caused by traumatic rhabdomyolysis (muscle breakdown) and the release of potentially toxic muscle cell components and electrolytes into the circulation. Crush syndrome can cause local tissue injury, organ dysfunction, and metabolic abnormalities such as acidosis (low blood pH levels), hyperkalemia (high potassium levels), and hypocalcemia (low calcium levels). Previous experience with earthquakes that caused major structural damage demonstrated that:

The incidence of crush syndrome was 2%15% Approximately half of those with crush syndrome developed acute renal failure Approximately half of those with acute renal failure needed dialysis A significant number of patients with crush syndrome (>50%) needed fasciotomy

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The ABCs of Disaster Medical Response

Clinical Manifestations of Crush Syndrome Sudden release of a crushed extremity may result in acute hypovolemia and metabolic abnormalities (reperfusion syndrome). This may cause lethal cardiac arrhythmias and sudden death. Further, the sudden release of toxins from necrotic muscle into the circulation leads to myoglobinuria (excretion of myoglobin in the urine), which may cause renal failure if untreated.

Muscle Ischemia and Necrosis from Prolonged Exposure (Local Effects)

CRUSH INJURY

CRUSH SYNDROME

Third Spacing: Fluid Retention in Extremities

Myoglobinuria

Electrolyte Abnormalities

Secondary Complications

Crush injury of pelvis with secondary crush syndrome

21 Definitive Management of Crush Syndrome Pretreat casualties with prolonged crush (>4 hours), as well as those who demonstrate abnormal neurological or vascular exam, with 12 liters of normal saline before releasing the crushing object whenever possible. If pretreatment is not possible, apply a tourniquet to the crushed limbs and maintain until initiation of IV fluids. Hypotension: Crush syndrome can cause massive fluid-shifts in casualties. Initiate (or continue) IV hydrationup to 1.5 L/hour. Renal Failure: Prevent renal failure through appropriate IV fluid hydration. Metabolic Abnormalities: Acidosis: Administer IV sodium bicarbonate until urine pH reaches 6.5 to prevent myoglobin deposits in kidneys.

Hyperkalemia/Hypocalcemia: Administer calcium, sodium bicarbonate, insulin/D50; consider kayexalate. Cardiac Arrhythmias: Monitor for cardiac arrhythmias and arrest, and treat accordingly.

Secondary Complications: Monitor casualties for compartment syndrome.

Monitor for Vascular Compromise: The Five Ps

TREATMENT ALERT! Prevention of crush syndrome through early treatment is key to reducing morbidity and mortality in crush injuries.

Pain Pallor Paresthesias Pain with passive movement Pulselessness

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The ABCs of Disaster Medical Response

3. BIOLOGICAL AGENTS
Biological terrorism is the use of microorganisms or toxins derived from living organisms to produce death or disease in humans, animals, or plants. Recent events have demonstrated the vulnerability of civilian populations to the threat of biological agents. The following disease agents are believed to have the greatest potential for bioterrorism:

Anthrax (bacteria) Tularemia (bacteria) Plague (bacteria) Smallpox (virus) Viral hemorrhagic fevers (virus) Botulinum (toxin) Ricin (toxin)

Cutaneous Anthrax

Smallpox , courtesy of the WHO

Chapter 5: The Threat of Terrorism

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Routes of Exposure Inhalation

The route of exposure of greatest concern with biological terrorist attacks is inhalation of the agent. In an attack, a terrorist might attempt to generate aerosols of the biological agent, which would produce particles of the right size and diameter to be inhaled deeply into the lungs where they would begin to cause illness. The aerosol could be odorless, colorless, and invisible due to its small particle size.

Oral
Oral routes of exposure for biological agents are believed to be less important, but are still significant. Contamination may occur directly or secondarily after an aerosol attack and may represent a hazard for infection or intoxication by ingestion. Ensuring that the food and water supply is free of contamination is an important function of public health and should be done as soon as possible after a biological attack.

Dermal
Intact skin provides the most effective barrier for many, but not all, biological agents. Mucous membranes and abraded or otherwise damaged skin can allow passage of some bacteria and viruses: these areas should be protected in the event of an attack.

Cutaneous anthrax caused by dermal exposure

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The ABCs of Disaster Medical Response

RESPONDING TO A BIOLOGICAL ATTACK Physical Protection

The most effective and important prophylaxis against biological agents is physical protection. A full-face respirator prevents exposure of the respiratory tract and mucous membranes, including conjunctivae, to infectious or toxic exposure, theoretically obviating the need for additional measures.

Decontamination
Any dermal exposure should be treated immediately by washing with soap and water. In addition, medical responders must guard against secondary contamination (i.e. contamination passed from the clothing of affected individuals) through the use of appropriate physical protection until decontamination is complete.

Prophylaxis and Treatment

Medical defenses against some biological agents are limited. Treatment options vary from agent to agent and include a variety of antibiotics such as ciprofloxacin and doxycycline for bacterial agents, and supportive therapy for viruses and toxins.

Physical protection is essential when dealing with unknown agents

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Indications of a Possible Biological Attack

A disease entity that is unusual or that does not occur naturally in a given geographic area, or combinations of unusual disease entities in the same patient population Suspected aerosol route of exposure Data suggesting a massive point-source outbreak Sentinel dead animals of multiple species High morbidity and mortality

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The ABCs of Disaster Medical Response

4. CHEMICAL AGENTS
On March 20, 1995, terrorism changed. For the first time, terrorists used a chemical agent against a civilian population. The nerve agent sarin (GB) was released in the Tokyo subway system by the Aum Shinrikyo cult, causing over 5,500 people to seek medical attention. Chemical agents are now a terrorist weapon. Most chemical warfare agents are liquids. However, chemical agents in liquid form must be dispersed in order to be maximally effective. This can be done in three general ways:

Aerosolizing it with an aerial sprayer (such as done with pesticides) Aerosolizing it in an explosion Allowing it to evaporate and dispersing the vapor

When used outside, a vapor will not remain in placeeven a light wind will dilute and carry it away. However, when dispersed inside a structure where no wind is present, the vapor will remain and the concentration will build, at least until the ventilation system removes itor possibly disperses it even further. There are five principal classes of chemical agents:

Nerve agents Vesicants (blistering agents) Cyanide Pulmonary agents Riot control agents

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NERVE AGENTS
Nerve agents cause biological effects by disrupting the normal mechanisms by which nerves communicate with muscles, glands, and other nerves. This causes hyperactivity in these structures before they fatigue and stop functioning. The important nerve agents are GA (Tabun), GB (Sarin), GD (Soman), GF, and VX. Nerve agents enter the body either through the skin or by inhalation through the lungs.

VESICANTS
Vesicants are substances that cause erythema (redness) and vesicles (blisters) on the skin as well as injury to the eyes, the airways and other organs. There are three types of vesicants that are considered chemical agents: sulfur mustard, lewisite, and phosgene oxime.

Vesicant (blistering agent)

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The ABCs of Disaster Medical Response

CYANIDE
Cyanide has a long history as a deadly poison because it causes death within minutes of exposure. Under temperate conditions, cyanide evaporates quickly to form poisonous gas or vapor. The forms of cyanide most likely to be used in a terrorist attack are hydrogen cyanide or cyanide chloride. Most signs and symptoms from cyanide poisoning are of central nervous system origin.

PULMONARY AGENTS
This class of compounds includes agents that cause pulmonary edema. The best known of these is phosgene, a liquid that evaporates very quickly and enters the body through the airways.

RIOT CONTROL AGENTS

Riot control agents, also known as tear gas, irritants, and lacrimators, are usually dispersed as a fine powder suspended in a liquid. Injuries from riot control agents are generally not serious and medical assistance is not usually sought after exposure to these agents.

Field Observations

Sulfur mustard has the scent of onions, garlic, or mustard. Lewisite has the scent of geraniums. Cyanide has the scent of bitter almonds and causes cherry red skin in its victims. Phosgene has the scent of freshly cut grass or hay.

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RESPONDING TO A CHEMICAL ATTACK

When responding to a chemical accident, one of the first things responders should do is establish a clean treatment area at least 300 yards upwind of the contaminated area. The clean treatment area is referred to as the cold zone, while the contaminated area is called the hot zone. Separating the hot and cold zones is the warm zone where decontamination occurs. The warm zone should be several hundred yards upwind from the contamination, and at least 50 yards from the cold zone. All responders must leave the hot zone via specially designated pathways into the warm zone where they will be decontaminated. If there are multiple casualties who have severe, life-threatening injuries, two medical care responders should work in the contaminated area, one to triage and one to administer emergency care, including the possible intramuscular administration of nerve agent antidotes, such as atropine. These responders must be in full protective equipment, including mask, gloves, suit, as described in Chapter 6..
HOT ZONE
Contaminated Area

(Decontamination)

WARM ZONE 50+ yards

COLD ZONE
(Clean Treatment Area)

at least 300 yards

WIND

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The ABCs of Disaster Medical Response

5. RADIOACTIVE AGENTS
Use of nuclear material by terrorists would likely involve one of four scenarios below. Fortunately, the most devastating scenarios are the least likely.

Detonation of a nuclear device: nuclear explosion Meltdown of a nuclear reactor: melting of the nuclear fuel within a reactor with limited release of radioactive materials into the environment if there is also a failure of the reactor containment structure Dispersal of material though use of conventional explosives: a radiation dispersal device (RDD) or dirty bomb Non-explosive dispersal of nuclear material: placing radioactive materials in public places

Nuclear Detonation

Reactor Meltdown

RDD Dirty Bomb

Simple Dispersal

Least Likely Most Harmful

Most Likely Least Harmful

Principles of Radiation Radiation is everywhere. Visible sunlight and radar are forms of non-ionizing radiation, as are television and radio signals. Cell phones use non-ionizing radiation to transmit our conversations. Ionizing radiation is radiation that can injure living tissue by transferring energy to vital cell components. Ionizing radiation is a natural part of our environment. Everyone is continuously exposed to a small amount of ionizing radiation, called background radiation. Sources of background radiation are both natural and man-made.

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Ionizing radiation transfers energy to cells in the body. If the radiation is strong enough, the cell will be killed. Less severe radiation exposure and damage may exceed the cells ability to repair itself or leave permanent alteration in the cells functioning or genetic material (e.g., predispose to development of cancer). There are two types of ionizing radiation:

Electromagnetic (wave) radiation Particle radiation

Ionizing electromagnetic radiation consists of gamma rays and x-rays. These waves have no mass or charge and can pass through tissue easily, irradiating casualties but leaving no radioactivity behind. They transfer kinetic energy to tissue as they pass through it, damaging the atoms that make up cells. Particle radiation consists of alpha particles, beta particles, and neutrons. Alpha and beta particles do not travel very far from their source and cannot penetrate skin effectively.

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The ABCs of Disaster Medical Response

Types of Ionizing Radiation Exposure

There are two general types of radiation exposure, which may occur alone or simultaneously: external irradiation (whole body irradiation or localized irradiation), and contamination (external or internal). External Irradiation occurs when all or part of the body is exposed to electromagnetic radiation (gamma rays or x-rays) from an external source. The degree of injury depends upon the dose of radiation received.

Dose = Exposure Time X Exposure Rate.

External Contamination occurs when radioactive material or debris (sometimes referred to as fallout) is deposited on the body and clothing. Generally, external contamination is not a serious medical problem as long as contaminated clothing is removed and the material is washed off of the body quickly. Internal Contamination occurs when radioactive materials are inhaled, ingested, or absorbed through open wounds. The assessment and management of internal contamination is more difficult than for external contamination but is not an urgent condition. Protection From Ionizing Radiation The cardinal rule of protection against radiation is TIME, DISTANCE, and SHIELDING. TIME: The shorter the amount of time you spend near the radiation source, the less radiation exposure you receive. The farther away you are from a radiation source, the less exposure you receive.

DISTANCE:

SHIELDING: Increasing the shielding around a radiation source, or around you, decreases exposure.

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Treatment Alert!
Casualties who have been irradiated are not radioactive themselves unless radioactive material (source material or fallout) has been deposited on or in their bodies.
Scene Control and Responder Protection

The incident commander will determine how much radiation exposure will be allowable for individual responders and will set the maximum allowable cumulative dose. All responders must be equipped with direct-reading individual dosimeters. When any responders total dose exposure reaches the maximum allowable dose as set by the incident commander, that responder must leave the site immediately and cannot return until the site has been decontaminated and is opened to the general public. There are no exceptions to this rule.

Triage of Radiation Casualties Since the clinical effects of all but the most severe radiation exposures are delayed, the clinical presentation of exposed casualties will be primarily related to conventional injuries.

Normal trauma triage procedures should be employed, but early closure of simple wounds is mandatory in irradiated casualties. Depending on the severity of the casualtys condition and triage status, decontamination can be done before, during, or after initial stabilization.

Treatment Alert!
Never delay major trauma care for radiologic decontamination!

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The ABCs of Disaster Medical Response

CHAPTER 6: Decontamination

econtamination is the process by which particulate, vapor, and liquid materials are safely removed from an exposed person without further contaminating the casualty, the environment, or rescuers. Decontamination is an important part of all disasters involving hazardous materials and weapons of mass destruction. There are two main goals in setting up decontamination at a medical facility: To protect the facility and its personnel from becoming contaminated, and thus further casualties To facilitate the treatment and triage of contaminated patients as rapidly as possible

Analysis of hazardous materials accidents has shown that up to 85% of the victims arrive at a healthcare facility without prehospital treatment or decontamination. Terrorist events, with their larger number of patients, unknown substances, and large numbers of worried well, increase the possibility of casualties arriving at a facility contaminated or potentially contaminated.

Removal of outer layers of clothing may reduce contamination by up to 85%. Showering with soap and water is among the most effective means of decontamination.
Personal Protective Equipment (PPE) Level A PPE denotes fully encapsulated suit, with over-gloves and over-boots integrated into the suit. Respiratory protection is a self-contained breathing apparatus. Level A protection is required for entry into an unknown hazardous environment. Level B PPE denotes a hooded suit, double gloves, over-boots, and a self-contained breathing apparatus and may be used for decontamination procedures for an unknown substance, and entry into hot zones where the agent is not caustic. Level C PPE is similar to Level B, but uses an air-purifying respirator instead of a self-contained breathing apparatus. Level C PPE can be used only after the hazardous substance has been identified, and upon verification of adequate oxygen in the environment.

Field Tip

Chapter 6: Decontamination

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The contaminated area is called the hot zone.

HOT ZONE

at least 300 yards

WIND

The area separating the hot and cold zones where decontamination occurs is the warm zone.

(Decontamination)

WARM ZONE 50+ yards

The clean treatment area is referred to as the cold zone.

COLD ZONE
(Clean Treatment Area)

Decontamination should always take place upwind and uphill from any potential contamination!

Decontamination of casualties in the warm zone by personnel in Level B PPE

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The ABCs of Disaster Medical Response

CHAPTER 7:

Psychological Response to Disasters

sychological trauma and other adverse psychological sequellae are frequently the side effects of events such as natural disasters and unintentional disasters caused by humans. With terrorism, the objective is to inflict psychological pain, trauma, and disequilibrium. It is important that planners, providers, and policy makers understand the importance of psychosocial issues. They are important not only in the care of disaster victims, but also in all aspects of the medical and public health response. These issues are also important in assuring that responders do not become victims themselves. Planners and providers must consider their own denial, vulnerabilities, and fears.

Characteristics of Disasters that Affect Mental Health

Not all disasters have the same level of psychological impact. Disaster characteristics that seem to have the most significant mental health impact are the following:

Little or no warning Serious threat to personal safety Potential unknown health effects Uncertain duration of the event Human error and/or malicious intent Symbolism related to terrorist target

Factors Impacting Psychological Response

Everyone who experiences a disaster, whether as a victim or as a responder, is affected by it. Fortunately, this does not mean that most will develop a mental health disorder. It does mean, however, that all individuals will have some type of psychological or emotional response to the event. Similarly, there are both individual and collective reactions that interact as individuals and communities recover from these extraordinary events.

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37

Factors affecting individual response to disasters include:

Physical and psychological proximity to the event Exposure to gruesome or grotesque situations Diminished health status prior to or as a result of the disaster Magnitude of loss Trauma history Degree of community disruption Pre-disaster family and community stability Community leadership Cultural sensitivity of recovery efforts

Factors impacting collective response to trauma include:

Psychological Sequelae of Disasters

Post-disaster responses are wide-ranging, from mild stress responses to full blown post-traumatic stress disorder (PTSD), major depression, or acute stress disorder. While many people may exhibit signs of psychological stress, relatively few (typically 15%25%) of those most directly impacted will subsequently develop a diagnosable mental disorder.

Field Tip
Most reactions to disasters are normal responses to severely abnormal situations.

Interventions

In cases where there is no diagnosed mental disorder, educational materials that help people understand what they and their families are experiencing is helpful. Brief crisis counseling should be provided, followed by referral when treatment is indicated.

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The ABCs of Disaster Medical Response

Worker Stress
Disaster workers who choose to be involved in this type of work gain great reward and satisfaction, but can also become secondary victims of stress and other psychological sequellae. This can adversely affect their functioning during and after an event. It can also adversely impact their personal well-being as well as their family and work relationships.

Signs of Stress in Workers

Some common signs of stress in workers include the following: Physiological signs of stress such as:

Fatigue, even after rest Nausea Fine motor tremors Tics Paresthesias Dizziness GI upset Heart palpitations Choking or smothering sensations Anxiety Irritability Feeling overwhelmed Unrealistic anticipation of harm to self or others Memory loss Decision-making difficulties Anomia (the inability to name common objects or familiar people) Concentration problems or distractibility Reduced attention span Calculation difficulties

Emotional signs of stress such as:

Cognitive signs of stress such as:

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39

Behavioral signs of stress such as:

Insomnia Hypervigilance Crying easily Inappropriate humor Ritualistic behavior Limited exposure to traumatic stimuli Reasonable hours Adequate rest/sleep Reasonable diet Regular exercise program Private time Talking to somebody who understands Monitoring signs of stress Identifiable endpoint for involvement

Managing Worker Stress On-Site

Fatigue contributes greatly to worker stress.

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The ABCs of Disaster Medical Response

International Trauma and Disaster Institute