Monday, July 14, 2008

Day 1 – Disaster Medicine and Management on Campus

Discussion of Communications and relevance to incidents.

  1. Establishing a model/guidelines for an incident.
  2. Extreme’s example – Hurricane Katrina, September 11, 2001; Anomalies
  3. Model basis should be realistic in scope/size to establish model.
  4. Playing 911 tapes from 9/11/01 – dialogue between responder and dispatch.  World trade center “send everyone” – it looks like it was intentional – could be a terrorist act.
  5. Communications theory model:
    1. Message transmitted
    2. Encoder/interpreter/decoder
    3. message reply
    4. Encoder/interpreter/decoder
      1. Osgood & Schramm Model
      2. If we don’t know the message has been received, then we don’t know if we communicated.
      3. Receiver –> Message –> Feedback
        1. Intolerable in a disaster scene.
        2. Order communicated, and don’t respond, insubordination.
  6. E.G. of spin - Audio tape from 50’s – demonstrating Atomic Bomb detonation.  Optimistic and demo – breaks in with an alert –the wind shifted and the fallout will fall on St. George, Utah. 
  7. Important to know the limitations
    1. Dead area
    2. Heavy radio traffic
    3. Their own voice – modulation of voice [enunciate]
    4. Open carrier [holds down push to talk]
    5. Mumblers…
  8. Engine 5 and 6 example [good and bad communication]
    1. Audio examples
    2. Yelling messages are unintelligible over radio communication and can over excite the situation.
    3. Catlett,VA Example.  Chief goes with a personal car –to scene.  The Chief radios pumping unit, radio back and forth over missing, Chief getting angry, Driver angry and sped up hill.  Hit by train.
  9. Characteristics of Effective Communication
    1. Clear and Calm
    2. No first or last names
    3. No ten codes
    4. No yelling
    5. Acknowledge message received
    6. No EMOTION
    7. Stay Clear and Calm
  10. Radio Communications
    1. Brevity (FCC 90.403C)
    2. Permissible (FCC 90.403D)
      1. “Ask self – is this message necessary?”
      2. Example of Meridian One fire [Philadelphia, PA] and the loss of three firefighters.
      3. Frequency and repeaters
      4. When planning – radios don’t meet the need of the bigger picture – towers etc. need to be factored into the equation.
    3. Interference (FCC 90.403E)
    4. Permissible (FCC 90.405)
    5. Virginia Tech discussion in the communications breakdown.  More to follow with John Giduck.

Wednesday, February 06, 2008

"Mujahideen Secrets ver 2.0". - A PsyOp and PR Strategy

Psychological Operations (PSYOP, PSYOPS), are techniques used by military and police forces to influence a target audience's emotions, motives, objective reasoning, and behavior. Target audiences can be governments, organizations, groups, and individuals, and are used in order to induce confessions, or reinforce attitudes and behaviors favorable to the originator's objectives. These are sometimes combined with black operations or false flag tactics.

This concept has been used by military institutions throughout history, but it is only since the twentieth century that it has been accorded the organizational and professional status it enjoys now.

The word is commonly used by governments, such as the United States, who do not wish to use the term propaganda, which would mar their image. The word propaganda has very negative connotations, and by calling it psychological operations instead, people are much more likely to support it, where they would be unlikely to support the use of "propaganda". This euphemistic naming scheme is ironically an example of psychological operations -- i.e. using psychological techniques to persuade a large number of people to support something that they wouldn't normally support.[1]Al-Qaeda-Security-Updated-2

1. Dougherty, William: "A Psychological Warfare Casebook", John Hopkins Univ. Press, 1979

 

--------------------------------------------------------------

Updated encryption tool for al-Qaeda backers improves on first version, researcher says
Jaikumar Vijayan

February 04, 2008 (Computerworld) A recently released tool that allegedly was designed to help al-Qaeda supporters encrypt their Internet-based communications is a well-written and easily portable piece of code, according to a security researcher who has analyzed the software.

However, messages that are encrypted using the tool, which is known as Mujahideen Secrets 2, should be relatively easy for law enforcement authorities to spot and track, said Paul Henry, vice president of technology evangelism at Secure Computing Corp. in San Jose.

Henry said that based on his analysis of the encryption tool, "it will not be a difficult matter for law enforcement to identify files created using this software," because it puts a unique fingerprint on them. "You may not be able to read the messages, but you will be able to figure out where it was sent from and to whom," he added.

Mujahideen Secrets 2 was released last month via an Arabic-language Web site set up by an Islamic forum called al-Ekhlaas. At the time, the password-protected Web site was running on a server that belonged to a Web hosting firm in Tampa, Fla., after previously being on a system owned by another company in Rochester, Minn. But the URL that the group was using on the server in Tampa is no longer working.

As of last week, the al-Ekhlaas site had been moved to a server owned by yet another hosting firm, this one based in Phoenix, Henry said. But the link to the site on that server also now appears to be broken.

The new encryption software is an updated version of an easier-to-crack tool that was released early last year by the same group. Henry said the copy of Mujahideen Secrets 2 that he evaluated was provided to him by J.M. Berger, a Cambridge, Mass.-based freelance journalist and documentary filmmaker who focuses on terrorism as well as science and business topics.

Mujahideen Secrets 2 is a very compelling piece of software, from an encryption perspective, according to Henry. He said the new tool is easy to use and provides 2,048-bit encryption, an improvement over the 256-bit AES encryption supported in the original version. What makes the update especially interesting, he noted, is the fact that it can be used to encrypt Yahoo and MSN chat messages in addition to e-mails.

Another interesting aspect of the tool is its ability to take a binary file and encrypt it in such a way that the file can be posted in a pure ASCII or text-only format, Henry added. As a result, individuals could use Mujahideen Secrets 2 to encrypt files and post them on sites that aren't even on the Internet -- for instance, on a telephone-accessed bulletin board system. "If you wanted to do something covert, that's one way of doing it," Henry said.

The new version of the tool also has a much better graphical user interface than the initial release did, he noted. And he thinks the tool's developers have done a better job of integrating bits and pieces of RSA Security Inc.'s encryption code in order to handle functions such as key generation and key management. Many of the mistakes they made in the first version seem to have been addressed in the new one, thereby making it harder to crack, he said.

In addition, the revamped tool is highly portable, Henry said. For instance, he explained, someone could put the software on a USB memory stick, go to an Internet cafe, plug in the USB device and run Mujahideen Secrets 2 to encrypt any communications from that cafe.

According to Berger, the new version of the tool sounds worrisome both because of its increased sophistication and the ease with which it can be used. The software appears to be designed for use by relatively low-level operators in the al-Qaeda hierarchy, he said.

The capabilities offered by Mujahideen Secrets 2 fit a pattern for al-Qaeda groups, Berger said, noting that the terrorist organization "has always been pretty current with what they use — cutting edge, but not bleeding edge."

Berger added that there is a "robust discussion" taking place within the counterterrorism community over the issue of online forums such as al-Ekhlaas being hosted on U.S.-based servers. Some people believe it is easier to monitor what's going on in the forums when they are hosted on U.S.-based servers, he said. Others, though, want the Web sites to be taken down immediately.

Source: http://www.computerworld.com/action/article.do?command=viewArticleBasic&articleId=9060939

EMERGENCY PERSONNEL AS TARGETS

Any WMD training exercise should be an all hazard approach for all the agencies in the system.

In the given area where the EMS work I would want a hazard analysis of the possibilities and a risk/vulnerability/threat assessment on paper so a plan could be devised as to priorities before any event occurred. In this way resources could be allocated, and training developed to prepare for the possibilities. The plan would have to be flexible to be capable be working in an unexpected event (all hazard).

Some specific training requirement needed.

a. All agencies would need to be familiar with the NIMS with a ICS chart with each division (operations, planning, logistics, and finance/administration) assigned to a qualified person and a backup for that person.

b. EOC developed with dedicated space with pre assigned personnel that would staff in an event of an emergency along with deciated equipment in place prior to the event (s)

c. The EOC should contain representatives from Fire, Police, EMS, hospitals, utility department, transportation, local officials, and volunteer organizations.

d. A redundant communication system tying all departments together on dedicated frequencies. I would require that the system be checked on a weekly basis with all departments included.

e. MOUs in place with neighboring communities and agreements with state, and federal departments if assistance is required.

f. I would want all hospital in the area to be trained in (HERT) Hospital Emergency Response Team course put on by FEMA

g. I would want the hospitals to have addressed the surge capacity requirements and made arrangements to comply.

h. I would have the police and fire department to pick designated personnel and have them attend the DHS courses at NMT, Nevada Test site, and FT. McClellan, Ala. so they could return and train the other personnel. I think this is very important to have the front line responders know what they are dealing with at the scene since a WMD event is not the typical crime scene they are familiar with and reorganization of ordinance is extremely important and in talking to policemen and firemen they have not had any training or if any training maybe one course and they will be the first as the scene.

i. According to Cole’s book “Terror” , every time a ER changes shikts in Israel they at least discuss their emergency plan of attack if they get a MCI on their shift.---that to me is training.

j. I would have table top, functional, and full scale exercises to improve cooperation with all department and the EOC at least two times per year.

k. There should be some type of incentive for the personnel to participate in the online course offered by FEMA (ISC) related to emergency events.

l. A continuing education program for IRIB, PRSBI, and MRTCBNE for the EMS, police and fire departments.

What considerations should be addressed when dealing with the threat of responder targets?

I think all first responders, in training, should have it drilled into their heads to take care of number one (themselves) first and have them understand the why of this rule. Too many young EMS personnel, with good intentions, go into this field to save lives and it is hard not to rush to the aid of an injured person and disregard their own selves, then they become a victim and add to the problem.

The three main guidelines for EMTs are life safety, property and environment, and scene stability.

I think the essential guidelines of the U.S. Fire Administration says it all;

1. Anticipate the presence of secondary devices at any suspicious event.

2. Search for a secondary device before moving into the incident area. This should be done by qualified personnel like EOD or hazmat and certainly not by the EMTs. In many incidents, the EMT can “eye ball” the area and get a feel if he can get a victim out quickly without injury to himself and not trigger a secondary device. This type decision can only be made at the time and no hard and fast rule can be made.

3. Avoid touching or moving anything at the site until cleared by the hazmat team or bomb squad. One should consider that an unconscious or dead victim could be triggered to a secondary device or even have a secondary device under them and activate the device with moving the victim. The adversary do not play by our rules.

4. Effectively manage the scene with boundaries, zones, triage area, etc. In fact in the suicide bomb course at NMT they establish the hot zone line at the site of the most distant fragment from the explosion. This line demarcates the hot or from the warm zone and there are relatively safe ways for an EMT to penetrate this zone and recovery victims with some training in this type scenario.

5. Evaluate victims and non essential personnel as quickly as possible.

6. Preserve the scene as much as possible for evidence since this is a crime scene.

If the event is cause by a LEE (low energy explosion) there will be incomplete explosive fragments that are hot and probably there are other explosive elements in the hot zone that are still active.

Again realistic training is the answer to getting the EMTs ready to handle a WMD and stay alive to work again.

References:

1. www. osha.gov/SLTC/emergencypreparedness

2. Prevention and Response to Suicide bombing Incidents Aug.28- Sept.1,2006 DHS, New Mexico Tech.

3. Incident response to Terrorist Bombings April 18-21, 2006 DHS New Mexico Tech.

4. Cole, Leonard Terror: How Israel Has Coped and What America Can Learn Indiana University Press 2007

Surveillance: For Good -- and for Evil

--------------------------------------------------------------

Editor's Note: This is the first in a series of articles addressing surveillance and countersurveillance.
Whether terrorists are attempting to assassinate a high-ranking government official, bring down a building or explode a bomb in a subway, their first order of business is to determine how best to set up the attack. To make such a determination, pre-operational surveillance of the target is vital.
If the target is a person, surveillance will determine his or her patterns of behavior; for a building, subway or other facility, the surveillance would help define possible weaknesses. In this way, attackers can determine the best time, location and method for the attack; how best to take advantage of the element of surprise - and how to escape afterward.


Terrorists, of course, are not alone in this regard. Carrying out an attack of any kind - a bank robbery, purse snatching or kidnapping, for example - requires that the perpetrators eye their target in advance, although the extent of the surveillance and its complexity will vary depending on the scale of the operation and the end goal. A purse snatcher, for example, might size up the victim for only a few seconds, while terrorists could assign a special team for this specific mission and then take up to several weeks to get the job done. Kidnappers and assassins also conduct surveillance of varying lengths to understand the target's daily routine, including the time he leaves the house in the morning and the route he takes to work.


U.S. and Jordanian intelligence indicates that the cell involved in the Nov. 9 suicide bombings in Amman, Jordan, conducted surveillance on all three hotels involved, though details about the length and degree of surveillance remain murky. The perpetrators of the April 1992 kidnapping of Exxon executive Sidney Reso conducted extensive surveillance and found that Reso was most vulnerable when he reached the end of his driveway on the way to work in the morning. Reso died while in captivity.


Stalkers or mentally disturbed individuals who fixate on someone surveil their victims in advance, although in many cases the stalker wants to get caught and thus does not need to be looking for possible escape routes. Also, a stalker usually strikes impulsively with little consideration given to the consequences. Stalkers or lone wolf attackers generally will conduct surveillance alone, making them difficult, but not impossible, to spot.


A great deal of surveillance also is conducted for purposes of collecting information. U.S. government employees and American businesspeople and business facilities overseas are routinely subjected to surveillance by local intelligence agencies in places such as China, France and Israel. The goal here is economic espionage aimed at keeping abreast of business activities - and stealing business secrets. Industrial spies, though working for themselves or for private concerns, have similar goals. Private investigators routinely observe people and places for their clients, usually to link an individual to a particular activity or event.


Not all surveillance is conducted for nefarious purposes, however. On the contrary, surveillance is an integral part of U.S. law enforcement and intelligence operations designed to prevent criminal and terrorist activity. Security personnel place closed circuit TV in retail stores and banks to deter criminals, while police officers stake out certain street corners to keep tabs on drug-traffickers, for instance.
Surveillance is a fact of life in the 21st century. In many ways, technological advances have made it easier for law enforcement to protect citizens. These advances, however, also have made it easier for those who wish to do harm.
---------------------------------------------------------------
The Spread of Technological Surveillance
Editor's Note: This is the second in a series of analyses on surveillance and countersurveillance.


As far back as the 5th century B.C., Chinese warrior-philosopher Sun Tzu went on record citing the paramount importance of using spies and clandestine reconnaissance to uncover enemy plans. At the time - and for centuries afterward - surveillance involved placing an operative close enough to a target to track his movements or overhear his conversations. Technological advances - especially those that have come along over the past century - have made it possible not only to watch and listen to others from afar, but to do so with ease.


Today, technical surveillance is conducted for a wide variety of purposes by individuals as diverse as terrorists, private investigators, activists, paparazzi, peeping toms, law enforcement and governments - and even by parents who listen in on their infants via baby monitors. These people are tracking a subject's activities, usually from a distance or remotely, using devices specifically designed or adapted for that purpose such as global positioning system (GPS) locaters, sophisticated listening devices and cameras of all kinds.


Al Qaeda used technical surveillance when targeting financial institutions in Washington, D.C., New York and Newark, N.J., and potential targets in Singapore in 2003. In New York, for example, several operatives sat in a Starbucks café across the street from their intended target and recorded various aspects of the institution's security measures and building access. Their notes and some of their videos were found on a laptop computer after authorities broke up the cell. Although al Qaeda's uses less-sophisticated technology than some - hand-held cameras versus micro-cameras and bionic ears, for example - the network's ability to conduct technical surveillance still is formidable.


Environmental activists, animal rights activists, anarchists and anti-globalization activists frequently surveil their subjects before staging a protest or "direct action" operations. Groups that target corporations for sabotage, such as the Earth Liberation Front, are especially sophisticated in the use of technical surveillance.


The Ruckus Society is a group devoted to training activists in "electronic scouting" - technical surveillance involving the use of remote cameras, GPS locators, frequency counters, programmable scanners and night-vision goggles. Program graduates, then, utilize high-tech equipment such as miniature remote cameras and "bionic ear" listening devices to conduct their surveillance. These activists frequently use programmable scanners and cameras to monitor security/police communications and activity in order to warn the saboteurs of an impeding response by law enforcement.


In some countries, it is not uncommon for Western business or government travelers to find telltale signs of listening devices in their hotel rooms, offices, meeting rooms and chauffeur-driven cars. In other instances, people have been caught spying on others in public bathrooms and changing rooms using tiny cameras that can be concealed in something as seemingly innocuous as an air freshener or electrical outlet.


The accessibility and miniature size of today's surveillance equipment makes it easy for just about anyone to clandestinely watch another. As technology continues to advance and surveillance becomes even more ubiquitous, methods to thwart such eavesdropping also will improve.
---------------------------------------------------------------


Physical Surveillance: Tailing Someone on the Move
Editor's Note: This is third in a series of analyses on surveillance and countersurveillance.


The image of the darkly clad private eye slipping in and out of doorways as he surreptitiously tails his subject around the busy city is straight out of the movies. The fact is, however, that physical surveillance often is carried out this way - using a lot of shoe leather. Technological advances and expert training in stealth have made the job easier than in the past, but when it comes down to it, there is no other way to keep an eye on a subject who is on the move.
Technical surveillance is carried out remotely, usually through video or audio recording equipment, and the subject remains in one place, such as a hotel room, home or office. Physical surveillance, on the other hand, is performed by human operatives, and often involves observing the subject's actions as he travels around outside the home or office.


In fact, private investigators lack the enormous human and technical resources needed to get the job done right. This type of surveillance requires a large number of highly trained operatives who must be constantly trained as improvements in techniques are implemented. This requires a significant support structure of instructors, facilities, money and material, as well as a well-developed network of communications to link the operatives together.
Physical surveillance can be broken down into two categories: static and mobile. Static surveillance favors the home team, and puts a visitor or newcomer to the scene of the surveillance at a disadvantage. If the operatives conducting the surveillance are familiar with the area, they can better blend in with the local scenery, and thus be harder to detect. They also can better anticipate their subject's moves. The Soviets used static surveillance against U.S. Embassy personnel in Moscow during the Cold War. On the other hand, if the subject is local and the operatives are from outside the area, the advantage goes to the subject, who would be in a better position to spot people in his environment who do not fit in - especially in small settings.


However, static surveillance - when carried out properly - is difficult to detect because good surveillance operatives blend in with their surroundings and make themselves as innocuous as possible. As creatures of habit, most people get used to their surroundings, and fail to notice things they see every day. By blending in with the scenery the subject sees every day, such as the local neighborhood or route taken every morning to work, the operative can effectively become invisible. Because of this, static surveillance requires a high degree of situational awareness - and a certain amount of paranoia - to detect.
Although static surveillance is the hardest type to detect and counter, it is expensive - as it can involve renting apartments, stores, street vendor kiosks and carts and other similar observation posts, known as "perches" in surveillance jargon. Because the operatives do not move, static surveillance requires that operatives be perched at close intervals so that they can keep a constant eye on the target. In general, only governments have the manpower and resources necessary to do this type of surveillance properly.


Mobile surveillance can be carried out in two ways: in vehicles or on foot. A wider area can be covered in vehicular surveillance - and is vital if the subject is traveling by car - although this type of surveillance does have limitations. Should the subject go into an office building, a subway or a shopping mall, for example, the operatives in the vehicle cannot follow. Because of this limitation, vehicular surveillance is usually carried out in conjunction with foot surveillance. The operatives on foot are in communication with the operatives in the vehicle. In addition, the operatives in the vehicle will often drop off one of their team to continue following the target. Mixed car/foot operations are effective because the target more often will focus on other pedestrians rather than the cars around him.


Depending on the resources available or allocated for a specific operation, mobile surveillance can range from an operative following the subject on foot - the hardest type of surveillance to accomplish without being detected - to an elaborate operation that puts the subject in a "bubble." The highest level involves multiple mobile and static surveillance teams all linked by communications and coordinating with one another to ensure that the subject's every movement is monitored - and that the team is not detected.


The bubble also provides protection against any erratic move the target might utilize to determine if he is being watched, or to ditch the surveillance. Therefore, if the team senses that the target has begun to "stairstep" (a series of deliberate turns intended to expose a surveillance team) through a residential neighborhood with very little activity on the street, the team using the bubble can wait outside the area instead of following the target through the maneuvers. Teams using a bubble will also frequently change "the eye" (the person directly watching the target) so that the target does not see the same face or vehicle twice. Again, in almost all cases, only a government has the resources and training to effectively provide this highest level of surveillance coverage.


In order to conduct surveillance uninterrupted over a long period of time, a combination of static and vehicular surveillance is often employed. Static surveillance operatives will stake out the subject's location - perhaps renting an apartment across the street from the person's home, and then give a "call out" to the mobile surveillance team when the subject moves. The static operative will advise the mobile team what direction the subject is going and if the subject is on foot or in a vehicle.


Physical surveillance - especially on a surveillance-aware target - is extremely difficult to carry out effectively, as it requires a great deal of training and practical experience. Criminals and terrorists who attempt to pull off an effective tail often lack the street skills to be effective, and often make mistakes that tip off the target. Because their objective can be to ambush - to kill or kidnap the subject - spotting physical surveillance is of critical importance.
---------------------------------------------------------------


Physical Surveillance: The Art of Blending In
Editor's Note: This is the fourth in a series of analyses on surveillance and countersurveillance.


Role playing is an important aspect of undercover surveillance work - and those who attempt it without sufficient training often make mistakes that can alert their subject to the fact that they are being watched, or raise the suspicions of law enforcement or countersurveillance teams.


Among the most common mistakes made by amateurs when conducting physical surveillance is the failure to get into proper character for the job or, when in character, to appear in places or carry out activities that are incongruent with the "costume." The terms used to describe these role-playing aspects of surveillance are "cover for status" and "cover for action." Good cover for status is an operative playing the role of a student studying in a coffee shop; bad cover for status is an operative dressed in business clothes walking in the woods. Good cover for action is an operative dressed as a telephone repairman pretending to work on phone lines - not playing chess in the park.


The purpose of using good cover for action and cover for status is to make the operative's presence look routine and normal. When done right, the operative fits in with the mental snapshot subconsciously taken by the subject as he goes about his business. Inexperienced surveillance operative, or those without adequate resources, can be easily detected and their cover blown.


An acronym used by government agencies when training operatives in effective surveillance is TEDD: Time, Environment, Distance and Demeanor. Failure to take into account these four elements is another amateurish mistake that can get the operative caught. The factors of time, environment and distance are important because a subject who notices the same person hovering around again and again at different times and locations is more likely to become aware that he is being watched. Demeanor refers to lack of cover or simply bad body language - which also can alert a subject to the presence of a surveillance team.
A surveillance operative also must be extensively trained to avoid the so-called "burn syndrome," the erroneous belief that the subject has spotted him. Feeling burned will cause the operative to do unnatural things, such as suddenly ducking back into a doorway or turning around abruptly when he unexpectedly comes face to face with his target. People inexperienced in the art of surveillance find it difficult to control this natural reaction.


These are just a few of the enormous number of mistakes that amateurs can make while conducting physical surveillance. They also can tip off the subject as to their presence by simply lurking around an area with no reason to be there, by entering or leaving a building immediately after the subject, or simply by running in street clothes.


Surveillance operatives following the subject in a vehicle also can make many mistakes, including:


Parking in the same spot for an extended period of time while sitting in the front seat.
Starting and stopping as the target moves.
Driving too slowly or too fast and making erratic moves or abrupt stops.
Signaling a turn but not making it.
Following a target through a red light.
Using two-way radios, binoculars or cameras from a vehicle.
Flashing headlights between vehicles.
Maintaining the same distance from the target even at varying speeds.
Pausing in traffic circles until the target vehicle has taken an exit.
vehicles that close on the target in heavy traffic but fall back in light traffic
Jumping from the vehicle when the subject stops his vehicle and gets out.
Parking a vehicle but remaining in the car.
Tipping off the subject as to a shift change by having one vehicle pull up and park while the other pulls away - especially in an area the subject knows well, such as near the home or office.
In general, because of the resources and extensive training required to avoid making these mistakes, only governments have the time and resources to make surveillance operations highly effective. Even then, some very basic mistakes can be made that can alert the subject to the presence of a surveillance operation.


---------------------------------------------------------------
Turning the Tables on Surveillants
Editor's Note: This is the fifth in a series of analyses on surveillance and countersurveillance.


Victims of planned hostile actions - such as kidnappings or killings - almost always are closely monitored by their attackers in advance of the operation. Such pre-operational surveillance enables the plotters to determine the best method of attack, as well as the best time and place to carry it out. Savvy countersurveillance, however, can go a long way toward thwarting a hostile act.


The cardinal rule for personal safety is for people to be aware of their surroundings at all times and to observe the behavior of others in the area. However, detecting surveillance - especially when it is performed well - often requires that one take extra precautions. One of the best ways for a person to determine whether he or she is being tailed is to use a surveillance detection route (SDR). By altering their behavior, those under surveillance can manipulate the situation, causing members of the surveillance team to act in ways that betray their presence and intentions. In fact, understanding that a potential victim can manipulate a surveillance situation is one of the most important lessons to be gleaned from this series.


Although hiring professional surveillance detection and countersurveillance teams - or drivers trained to provide more than a smooth ride - are obvious choices, not everyone who is at risk has the resources to do so. Individuals, however, can take a number of steps to determine whether they are under hostile surveillance. Techniques for manipulating surveillance teams include stair-stepping, varying routes and departure times, using intrusion points, and timing stops.


The most common and effective SDR tool is the channel - a long, straight corridor that has several exits or routes at the far end. A person who wants to ensure he is not being tailed can use the channel to force the surveillant to follow closely behind. This is because the operative cannot parallel the subject's route and cannot know which way the subject will go at the end of the channel. Natural channels are long narrow bridges and sections of highway that have no exits or overpasses, but that branch out in a number of routes on the far side. The subway is also a type of channel. Most people likely use such channels in their daily routes but are unaware of them.


Stair-stepping involves making turns - in a vehicle or on foot - that deviate slightly from the most direct route to the destination. During a stair-stepping sequence, a surveillant is likely to reveal his presence by staying with his subject during the series of turns - a common mistake among amateur surveillance operatives who fear losing sight of the target. The subject, however, should not make sudden, unnatural movements, or the surveillance team will break off without revealing its presence.


By varying routes and departure times, the subject can cause surveillants to go into action abruptly in order to compensate for the change in plans. Unless it has a wide area covered, the team could be forced to break off surveillance or act more overtly to prevent losing its target. Varying departure times from fixed locations such as the home or office also can be quite effective because it can force the surveillants to remain in one place longer than anticipated - and thus attract attention.


An intrusion point is a place along a person's route, preferably with a secondary exit such as a back door, where a surveillance target can stop and see whether anyone is following. If the intrusion point has a secondary exit, the subject can give the surveillance team the slip by heading out the back door. If the surveillance team knows the place, however, it could very well have another surveillant waiting by the secondary exit. This kind of coverage generally requires the kind of resources that only a government can lavish on a surveillance operation. Intrusion points - like all parts of the SDR - cannot be random. They should be planned in advance and worked into a daily routine.


Finally, conducting timing stops is one more way to spot hostile surveillance. A timing stop is a place where a person stops and looks back before reaching the final destination to ensure he is not being tailed. It doesn't have to be long - especially in a vehicle.


Physical threats to individuals from terrorists, assassins, kidnappers or even stalkers are site-dependant. The assailants choose the location and timing of their attack based on criteria that gives them the best chance of successfully carrying out the attack and - unless the attacker is mentally disturbed or on a suicide mission - of escaping. These criteria include restricting or controlling the target's ability to maneuver or escape, and providing optimal cover for any surveillance or attack team.


Another way to safeguard against potential hazards is by conducting an analysis of one's normal route to identify points of vulnerability such as overpasses, bridges and tunnels, to minimize hazards and deny potential attackers any advantage. Route analysis can also identify potential attack sites - points along the route that restrict the target's movement, and provide cover and an escape route for the attackers. Once a potential attack site is identified, possible vantage points - or perches - for hostile surveillance or attack teams should be watched.


High-profile individuals or anyone who resides in a high-crime or -terrorism area such as Mexico City or Baghdad should take the initiative and identify surveillants before they have the opportunity to strike. Once hostile surveillance has been identified, immediate action should be taken and assistance called in.
© Copyright 2008 Strategic Forecasting Inc.
---------------------------------------------------------------

Draft National Response Framework Released for Public Comment

Draft National Response Framework Released for Public Comment
Release Date: September 10, 2007
For Immediate Release
Office of the Press Secretary
Contact: 202-282-8010 


The Department of Homeland Security (DHS) released today the draft National Response Framework (NRF), successor to the National Response Plan, for a 30-day public comment period. The Framework, which focuses on response and short-term recovery, articulates the doctrine, principles and architecture by which our nation prepares for and responds to all-hazard disasters across all levels of government and all sectors of communities. The Framework is responsive to repeated federal, state and local requests for a streamlined document that is shorter, less bureaucratic and more user-friendly.


The Framework is intended for senior elected and appointed leaders, such as federal agency heads, state governors, mayors, tribal leaders and city managers. Simultaneously, it informs emergency management practitioners by explaining the operating structures and tools routinely used by first responders and emergency managers at all levels of government.


“The Framework recognizes that most incidents are managed locally,” said Homeland Security Secretary Michael Chertoff. “But when needed to support state and local officials as they respond to a disaster, the Framework establishes the playbook for the federal coordination of resources and assets to manage disasters of all sizes and scope.”


The Framework incorporates a number of key recommendations from more than 700 individuals representing federal, tribal, state and local governments, non-governmental agencies and associations, and the private sector, who participated in a review process that began in September 2006. In addition to the core Framework, supporting documents, including Emergency Support Functions, Support and Incident Annexes and other appendices have also been updated, expanded and remain an integral part of the Framework. These documents are available at the newly-created NRF Resource Center, which is available online at www.fema.gov/nrf. This resource center will be continuously updated as additional supporting materials are created or revised.
The 30-day comment period provides interested parties with the opportunity to provide feedback on the document. A comment form has been circulated to various departments, agencies and key stakeholders.


Individuals who wish to submit comments can obtain a comment form and instructions for submission online at www.fema.gov/nrf.
In addition to the core Framework, supporting documents, including Emergency Support Functions, Support and Incident Annexes and other appendices have also been updated and remain an integral part of the Framework. There will be a 60-day comment period for these supplemental documents. During this period, the existing National Response Plan remains in effect.*
###

From a colleague...

I have had the unfortunate experience of dealings with suicide bombers while stationed in Iraq. My first close call occurred while we were performing a humanitarian mission to a local Sheik's dwelling. Within seconds of my climbing back into the Bradley after caring for the Sheik's nephew, a man rushed up to the vehicle and detonated himself. We were all fortunate the blast did not injure any of us. However, the suicide bomber was "de-masked". Open the attachment only if you have a strong stomach.

On more than one occasion I witnessed, and was called to the scene of suicide bombers that had utilized vehicle devices. Several of the incidents were not terrorists at all. They were unfortunate civilians that were forced to commit such an atrocity. A typical scenario was that the civilian's home would be raided by insurgents. The man of the house would be told that he would do as he was told or his family would be killed. The individual would then be either handcuffed to the steering wheel, or tied to the seat of the explosive laden vehicle.  A remote detonator was typically utilized. The individual knew either way he was going to die but at least he can save his family. Could these tactics be implemented in the States?   

mahmudiyah_2_550

EXPLOSIVES AGENTS AS WMD's

1. Pre-hospital and Disaster Medicine: April-June 2004 Mass-Casualty Terrorist Bombing in Istanbul, Turkey, Nov. 2003: Report of the events and Pre-hospital Emergency Response.

Turkey with a population of 67 million, sits at the geographic, political, and cultural crossroads between Europe, Asia, and the Middle East. Turkey is a secular democracy with 99.8% muslin population. Between 1984 and 2003 there have been between 30,000-35,000 deaths related to terrorism.

A complex, retrospective, descriptive study was performed, using open source reports, interviews, hospital records, and direct measurement of distances between the bombing sites and the medical facilities.

This paper is a study of the two largest terrorist attacks in turkey’s history and the pre hospital response.

On Nov. 15, 2003 there were two truck bombings: 1. In front of Neve Shalom Synagogue, in crowed area, destroying the front of the Synagogue causing a creator 2 m deep and windows knocked out of buildings for 200m’s. 2. Within five minutes a second bomb at the Beth Israel Synagogue. Both bombs contained in trucks, an thought to be 400kg AMSO4.; killing 30 and injuring an estimated 300. Most injuries were on the street, since the worshippers inside the synagogue were protected by the front of the building.

As a result only six immediate deaths were reported in victims located within the two synagogues. Most injuries on street caused by shards of glass, masonry, and fragments of cars. At each bombing a corpse were found with wires attached, suggesting a suicide bomber. Great Eastern Raiders and Al Qaeda claimed responsibility.

Immediately post attack, bystanders performed spontaneous search and rescue at both sites. The first ambulances with EMTs arrived within 3 minutes. At 15 minutes after explosion, 26 ambulances were now at both sites and Istanbul police were beginning to establish scene security. At one hour post blast there were 50 ambulances with 170 personnel on scene.

The City’s Health Department reported that the victims were treated at 23 different hospitals. A total of 248 injuries survivors were sent to 16 medical facilities. Nine were government hospitals, six private hospitals; one is private clinic without ER. Together these 16 facilities have 4930 in- patient beds and 218 ED beds and all 16 are located within 11km of the bombing sites. Sixty nine injured survivors sought care at American Hospital (AH) 6 km away, the greatest number to any medical facilities that day; 86% with lacerations, 10% fractures, and 2% intracranial injuries and were hospitalized.

After the attack, many people tried to contact their families, rapidly overloading the communication system which subsequently failed.

On Nov. 20, 2003, a suicide bomber struck again, attacking two British facilities in Istanbul in two nearly simultaneous events. The first bombing at 1055, when a truck loaded with an estimated 700kg AMSO4 & AMN2 exploded in front of HQ of Hong Kong Shanghai Banking Corp., second largest world bank; destroying the first two floors of the building. A 3m creator was left in the street outside the bank.

At 1100, approximately 8km away, another truck with similar load, crashed through the gate of the British consulate and exploded. The consulate is only 300m from the Neve Shalom Synagogue.

Together the two bombings killed 33 persons and injured an estimated 450 others.

A famous Turkish actor, Kerem Yilmazer in his car outside the bank and the British consul general, Robert Short died in the consulate. The same group claimed responsibility for the bombing.

Immediate after the blast , bystanders began the search and rescue operation with their bare hands.

First responders responded within 3-5 minutes but did not don respiratory protection although ammonia permeated the scene as it did on the bombing of Nov. 15. TV crews were on the scene within 12 minutes and ambulances had difficulty responding due to debris on the streets. Many persons with minor injuries departed the scene and sought care at the hospitals. Bystanders help carry the bodies out to the ambulances.

Once again the police were unable to establish a secure perimeter for the first 15-20 minutes. There was little triage at either bomb site. A small clinic within 15 minutes of the blast was overrun with over 50 injuries victims, some of which, 23 severely injured victims, had to be transported to other hospitals for more detained treatment.

According to the Minister of Health the victims were treated at a minimum of 24 medical facilities. All facilities were located within 16 km of blast site.

Taksim Education and Research State Hospital the closest hospital to blast, 2km, received 184 injured survivors within one hour of blast, of which 88 (48%) were brought by ambulance. An additional 12 victims were brought by ambulance, but DOA. The remaining 96 (52%) arrived on foot.

Within five minutes of receiving notice of the blast, TERSH cleared the first three floors for the victims; 1st floor had 15 beds ED and 12 specialty beds; 2nd floor 40 bed general surgery ward; 3rd 40 beds GYN ward and the minor walk ins were treated in the parking lot.

The hospital grounds were packed with hundreds of people looking for relatives.

The AAR found important “lesions learned” as listed below.

1. Casualty mal-distribution to hospitals.

2. Not distributed to hospital according to injury but to hospitals closest to bombing.

3. Distributed to government hospitals rather to than to private or other hospitals and this was thought to be due to hospital cost of care; government care is free.

4. Little on scene command and control and not much triage at scene.

5. Istanbul sent every available ambulance to scene and many were not needed and left other areas of city uncovered for emergencies.

6. EMS unable to coordinate the distribution of casualties with hospital based on the hospital capacity to provide emergency care.

7. Istanbul police unable to rapidly control scene, resulting in bystanders and media converging on scene, getting in the way of the responders.

8. No initial scene assessment for secondary devises.

9. Government lacked official mechanism for notifying the public and keeping the public informed about the evolving situation on each date.

Conclusion:

There were two suicide truck bombings on 15 & 20 Nov. 2003; these were the two largest terrorist attacks in modern Turkish history. Collectively killing 63 persons and injuring an estimated 750 more. The majority of victims has secondary blast injuries that were relatively minor. The response was heroic, but victims were mal distributed to medical facilities. The first responders put themselves at risk to secondary devises and the public was not apprised of the evolving situation.

2. North Carolina Medical Journal, September/October 2002 Volume 63 # 5.

Mass casualty Victim “Surge” Management; Preparing for Bombings and Blast Related Injuries with Possibility of Hazardous Material Exposure. Harry W. Severance MD, FACEP.

The author stresses the fact that bombing of civilian structures, both here and abroad, is a real and ongoing threat. In the US alone between1980-1990 there were 12,216 intentional bombings. North Carolina is not immune from such events. Approximately 200 bombings were reported in state from 1996 to Sept. 1998.

Injuries can result from accidental explosions in factures or fuel depots or intentional bombing like the World Trade Center in 1993, by terrorist, that reported unsuccessfully use of cyanide gas in the bomb.

The author gives the patho-physiology of blast injuries. Injuries are classified as primary, secondary, tertiary, and quaternary. Primary injury occurs when the person is initially hit with the high pressure wave plus the heat generated by the blast. The secondary injury is caused by the debris accelerated by the pressure wave, resulting in penetrating injuries. The tertiary injury is the result of the person’s body being hurled (thrown) into another object (s) resulting in generalized body injury to include head, crushing, extremity fractures and amputations and abdominal injuries. Quaternary injuries referred to all other injuries not covered above to include organ failure and infections.

Explosives from intentional bombing and other blast are among the few instantaneous traumatic events that can produce massive numbers of casualties, of which approximately 10-15% are severe and the remainder are minimum to moderated injured and the so called “walking wounded” which can flood the hospitals and totally over run the facilities.

Even after the institution of the ICS and NIMS protocol, most hospital in this country are

“It is not likely that any North Carolina Trauma Center could maintain hazardous materials precaution while providing decontamination, primary intervention, and definitive surgical intervention services to more than 1-4 cases/hour”.

The crucial component of a local disaster or MCI planning is a unified mechanism for rapidly disposition of patients. This has to start at the scene with police perimeter control and crowd control, directing victims away from the blast site, setting up triage areas and initial treatment areas for the not so serious injuries, decontamination of victims and preventing the multitude from of patients going to hospitals.

Hospitals, urgent care clinics, and others providers should work proactively with area pre-hospital event command system to develop plans for ultimate patient disposition.

Conclusion:

Bombing and other blast related events place severe demands on pre-hospital and in-hospital systems. The resulting surge of victims can overwhelm the resources of any facilities. The challenges become even more daunting when there is possible hazard exposure.

Local communities must take the lead in developing incident command system for the initial management of the event.

Ultimately management and disposition of large number of casualties, especially if contaminated, cannot follow standard patient management protocol.

Case Study related to MCI and explosives.

Reduction in critical mortality in urban casualty incidents; analysis of triage, surge, and resource use after the London bombing on July 7, 2005

The Lancet Vol. 368 December 23/30, 2006 2219-2225

The terrorist bombing in London on July 7,2005, produced the largest mass casualty event in the UK since WW2.

The aim of the study was to analyze the pre-hospital and in hospital response to the incident and identify processes that optimized resources used and reduce critical mortality.

The study was retrospective analysis and the data for injuries, outcome, triage, patient flow, and resources used was obtained by the review of emergency services and hospital records.

There were 775 casualties, 56 deaths, 53 at the scene. 55 patients were triaged prior to dispatch and 20 victims were critically injured. The critical mortality was low at 15%. The overall triage rate was reduced where advanced pre-hospital teams did the initial triage.

The Royal London Hospital received 194 casualties, with 27 classified seriously injured. Maximum surge rate was 18 seriously injured patients/ hour and the resuscitation room capacity was reached within 15 min., 17 patients needed surgery and 264 units of blood products was used in the first 15 hours, which is close to the hospital’s routine daily blood use.

Critical mortality was reduced by rapid advanced major incident management. Hospital surge capacity can be maintained by repeated effective triage and implementing a hospital wide damage control philosophy, keeping investigations to a minimum, and transferring patients rapidly to definitive care.

The two main fundamental goals of a disaster response is rapid evacuation of all casualties from the event and reduce the mortality of critically injured patients. This is vital where there is danger of structure collapse or secondary explosions. There is a liner relationship (studied done on previous bombings) between over triage and critical mortality. This paper describes how critical mortality in mass casualty events can be reduced by efficient management of surge at every stage of a disaster response.

The overall mortality rate of mass casualty event is skewed by the large number of walking wounded, and the critical mortality rate is more indicative of effectiveness of the trauma system and disaster response.

This study feels that a more simplified triage system would enhance management at the scene. They used two classifications; seriously injured or walking wounded rather than the four tear system.

Surge, over triage, and under triage can be reduced in a stepwise fashion by systematic reassessment, reprioritization, and redirection of patients at every stage, and should happen anywhere in the system where resources are constrained. For example, London-HEMS team did few advanced on scene interventions, but instead focus on identification and extraction of the most severely injured patients.

Management of Chemical Incidents

Management of a chemical incident


Proper drilling of the facility or group appropriate response plan for a MCI:


MaHIM, HEICS, ICS, NIMS - this should be done locally or regionally. [1]


HVA - Defining potential hazards within the local geographic area is essential to prepare all-inclusive realistic plans. [1]


Integrate plans to handle a chemical WMD into the existing disaster planning.


Define - chain of command, critical assets and define the roles of the members in the chain (this should be handled under the MaHIM etc).


Define objectives for the staff to achieve during the incident and define SOP that must be enacted during an incident.


Additionally recognize the differences in staffing levels, etc during different periods of the day/week.


Clearly appoint a safety officer to monitor the well being of staff working in PPE, to maintain contamination control, and various other hazards. This officer should also ensure proper decontamination of all patients, staff, and equipment. Most importantly the officer will maintain the well being of the staff and prevent compromise of the staff by chemical agents.
A clear plan to decontaminate patients should be established (See Jane's manual for details on how to decontaminate). HAZMAT should handle decontamination; however, this will not always be the case. Thus, on site decontamination will need to be incorporate into planning.


The facility must, according to JCAHO, work with and coordinate with the community. This will help to mitigate the impact of a large scale incident.


A notification and communication system should be established to ensure clear and concise delivery of relevant info during an incident to all groups.


Steps to prepare public health agencies for chemical attacks include the following (MMWR, 2000):


Enhance epidemiologic capacity for detecting and responding to chemical attacks.


Enhance awareness of chemical terrorism among EMS personnel, police officers, firefighters, physicians, and nurses.


Stockpile chemical antidotes.


Develop and provide bioassays for detection and diagnosis of chemical injuries.


Prepare educational materials to inform the public during and after a chemical attack.


Communication and information dissemination - thus staff must be prepared to shift locations and facilitate communication. Cell phones will more than likely be inundate. Thus land lines, electronic mail, or even radio can be used to communicate across the channels.


Hospitals will also need to prepare for inquires into patient status from family/friends of those involved in the incident.
Surge plans may need to be enacted depending on the scale of the incident, thus, Mutual Assistance agreements should be in place or external sites identified to place patients.
Identify and work with external healthcare providers (pharmacists, nurses, doctors, etc) to help treat patients.
Information should be communicated accurately to the media, fake press conferences are a terrible idea (I'm looking at you FEMA). This information should be communicated by the designated information officer.


At all times, personnel need to be protected, security and PPE wise.


The decontamination area must be clearly demarcated, cold, warm, hot and patients triaged.


All patients belongings tagged and bagged. patients decontaminated, triaged and admitted as needed.

Photograph/barcode patients and their belongings to assist in tracking.


Activate access to the strategic national stockpile, if warranted.
Maintain human remains, as this is a crime scene.


Broader, establish counseling to deal with psychological aspects during and post incident.


Map out the region, define congestion points and establish clear evacuation routes during emergencies.


Define a logistical plan to provide equipment and supplies to staff and patients.


Define a broader security plan; work with local police to protect the facility (Riot syndrome).


Train, train and train again. Drill, Drill and Drill again...


Post incident, an after action analysis should be done to identify what was done right, wrong and to help adjust for improvements.
Lastly, cleanup the areas contaminated or infected.

Decontaminate all collected belongings. Follow chain of custody. Establish and prep psych plans for the community.
Source and citation:
1.        Gum, Robert M., and John D. Hoyle. "CBRNE - Chemical Warfare Mass Casualty Management." CBRNE - Chemical Warfare Mass Casualty Management. eMedicine. http://www.emedicine.com/emerg/topic895.htm.

Post reply

Medical Management Guidelines for Unidentified Chemical Agents

Medical Management Guidelines for Unidentified Chemical
General Information


Description
All attempts should be made to determine the identity of the hazardous material before the Unidentified Chemical guideline is used. Responders should obtain assistance in identifying the chemical(s) from container shapes, placards, labels, shipping papers, and analytical tests. General information on these identification techniques is located in Managing Hazardous Materials Incidents Volumes I and II. The Unidentified Chemical protocol provides basic victim management recommendations but the techniques for a specific chemical could provide information which would allow more effective patient treatment.

Prehospital Management


Potential for Secondary Contamination. The route and extent of exposure are important in determining the potential for secondary contamination. Victims who were exposed only to gas or vapor and have no gross deposition of the material on their clothing or skin are not likely to carry significant amounts of chemical beyond the Hot Zone and are not likely to pose risks of secondary contamination to response personnel. However, victims whose skin or clothing is soaked with liquid chemical or victims who have condensation of chemical vapor on their clothes or skin may contaminate others by direct contact or by off-gassing vapor. If the victim has ingested a chemical, toxic vomitus may also pose a danger to others through direct contact or off-gassing vapor.


Hot Zone


Rescuers should be trained and appropriately attired before entering the Hot Zone. If the proper equipment is not available, or if rescuers have not been trained in its use, call for assistance from a local or regional HAZMAT team or other properly equipped response organization.


Rescuer Protection


When a chemical is unidentified, worst-case possibilities concerning toxicity must be assumed. The potential for severe local effects (e.g., irritation and burning) and severe systemic effects (e.g., organ damage) should be assumed when specific rescuer-protection equipment is selected.


Respiratory Protection: Pressure-demand, self-contained breathing apparatus (SCBA) should be used in all response situations.


Skin Protection: Chemical-protective clothing should be worn when local and systemic effects are unknown.


ABC Reminders
Quickly ensure a patent airway. If trauma is suspected, maintain cervical immobilization manually and apply a cervical collar and a backboard when feasible.


Victim Removal


If victims can walk, lead them out of the Hot Zone to the Decontamination Zone. Victims who are unable to walk may be removed on backboards or gurneys; if these are not available, carefully carry or drag victims to safety.
Rescuer Protection


If the chemical or concentration is unidentified, personnel in the Decontamination Zone should wear the same protective equipment used in the Hot Zone (see Rescuer Protection, above).


ABC Reminders
Quickly ensure a patent airway. Stabilize the cervical spine with a collar and a backboard if trauma is suspected. Administer supplemental oxygen as required. Assist ventilation with a bag- valve-mask device if necessary.


Basic Decontamination
Victims who are able and cooperative may assist with their own decontamination. Remove and double-bag contaminated clothing and personal belongings.


Flush exposed or irritated skin and hair with plain water for 3 to 5 minutes. For oily or otherwise adherent chemicals, use mild soap on the skin and hair.


Flush exposed or irritated eyes with plain water or saline for at least 5 minutes. Remove contact lenses if present and easily removable without additional trauma to the eye. If a corrosive material is suspected or if pain or injury is evident, continue irrigation while transferring the victim to the Support Zone.
In cases of ingestion, do not induce emesis. Victims who are conscious and able to swallow should be given 4 to 8 ounces of water. Obtain medical care immediately.


Transfer to Support Zone
As soon as basic decontamination is complete, move the victim to the Support Zone.


Support Zone
Be certain that victims have been decontaminated properly (see Decontamination Zone above). Victims who have undergone decontamination or who have been exposed only to gas or vapor and who have no evidence of skin or eye irritation generally pose no serious risks of secondary contamination. In such cases, Support Zone personnel require no specialized protective gear.


ABC Reminders
Quickly ensure a patent airway. If trauma is suspected, maintain cervical immobilization manually and apply a cervical collar and a backboard when feasible. Ensure adequate respiration; administer supplemental oxygen as required. Ensure a palpable pulse. Establish intravenous access if necessary. Attach a cardiac monitor.


Additional Decontamination
Continue irrigating exposed skin and eyes, as appropriate.
In cases of ingestion, do not induce emesis. If the patient is conscious and able to swallow, administer 4 to 8 ounces of water if it has not been given previously. Obtain medical care immediately.


Advanced Treatment
Intubate the trachea in cases of respiratory compromise. When the patient's condition precludes endotracheal intubation, perform cricothyroidotomy if equipped and trained to do so.
Treat patients who have bronchospasm with aerosolized bronchodilators. Use these and all catecholamines with caution because of the enhanced risk of cardiac dysrhythmias after exposure to certain chemicals.


Patients who are comatose, hypotensive, or have seizures or cardiac dysrhythmias should be treated according to ALS protocols.


Transport to Medical Facility
Report to the base station and the receiving medical facility the condition of the patient, treatment given, and estimated time of arrival at the medical facility.


If a chemical has been ingested, prepare the ambulance in case the victim vomits toxic material. Have ready several towels and open plastic bags to quickly clean up and isolate vomitus.


Multi-Casualty Wage
All exposed patients should be transported to a medical facility for evaluation.


Asymptomatic patients who have not had direct chemical exposure can he discharged from the scene after their names, addresses, and telephones numbers are recorded. Those discharged should be advised to seek medical care promptly if symptoms develop.


Consult with the base station physician or regional poison control center for advice regarding triage of multiple victims.

Emergency Department Management
Potential for Secondary Contamination. Victims who were exposed only to gas or vapor and have no gross deposition of the material on their clothing or skin are not likely to carry significant amounts of chemical beyond the Hot Zone and are not likely to pose risks of secondary contamination to hospital personnel. However, victims whose skin or clothing are covered with liquid or solid chemical or victims who have condensation of chemical vapor on their clothes or skin may contaminate hospital personnel and the ED by direct contact or by off-gassing vapor. If the victim has ingested a chemical, toxic vomitus may also pose a danger through direct contact or off-gassing vapor.


Decontamination Area
Previously decontaminated patients and patients exposed only to gas or vapor who have no evidence of skin or eye irritation may be transferred immediately to the Critical Care Area. Other victims will require decontamination as described below


ABC Reminders
Evaluate and support airway, breathing, and circulation. Intubate the trachea in cases of respiratory compromise. If the patient's condition precludes intubation, surgically create an airway.
Treat patients who have bronchospasm with aerosolized bronchodilators; use these and all catecholamines with caution because of the possible enhanced risk of cardiac dysrhythmias.
Patients who are comatose, hypotensive, or have seizures or ventricular dysrhythmias should be treated in the conventional manner.


Basic Decontamination
Patients who are able and .cooperative may assist with their own decontamination. Remove and double-bag contaminated clothing and personal belongings.


Flush exposed or irritated skin and hair with plain water for 3 to 5 minutes. For oily or otherwise adherent chemicals, use mild soap on the skin and hair. Rinse thoroughly with water.
Flush exposed or irritated eyes with plain water or saline for at least 5 minutes. Remove contact lenses if present and easily removable without additional trauma to the eye. If a corrosive material is suspected or if pain or injury is evident, continue irrigation while transferring the patient to the Critical Care Area.
In cases of ingestion, do not induce emesis. Administer 4 to 8 ounces of water to dilute stomach contents if the patient is conscious and able to swallow. Immediately transfer the patient to the Critical Care Area.


Critical Care Area
Be certain that appropriate decontamination has been carried out. (See Decontamination Area, above.)


ABC Reminders
Evaluate and support airway, breathing, and circulation as in ABC Reminders, page 7. Establish intravenous access in seriously ill patients. Continuously monitor cardiac rhythm.
Patients who are comatose, hypotensive, or have seizures or ventricular dysrhythmias should be treated in the conventional manner.


Inhalation Exposure
Administer supplemental oxygen by mask to patients who have respiratory complaints. Treat patients who have bronchospasm with aerosolized bronchodilators; use these and all catecholamines with caution because of the potential or possible enhanced risk of cardiac dysrhythmias.


Skin Exposure
If concentrated chlorine gas or chlorine-generating solutions contact the skin, chemical burns may occur; treat as thermal burns. If the liquefied compressed gas is released and contacts the skin, frostbite may result. If a victim has frostbite, treat by rewarming affected areas in a water bath at a temperature of 102 to 108ºF (40 to 42ºC) for 20 to 30 minutes and continue until a flush has returned to the affected area.
Because of their larger surface area:body weight ratio children are more vulnerable to toxicants absorbed through the skin.


Skin Exposure
If chemical burns are present, treat as thermal burns.


Eye Exposure
Ensure that adequate eye irrigation has been completed. Test visual acuity. Examine the eyes for corneal damage using a magnifying device or a slit lamp and fluorescein stain. For small corneal defects, use ophthalmic ointment or drops, analgesic medication, and an eye patch. Immediately consult an ophthalmologist for patients who have severe corneal injuries.


Ingestion Exposure
Do not induce emesis. If the patient is alert and charcoal has not been given previously, administer a slurry of activated charcoal. If a corrosive material is suspected, administer 4 to 8 ounces of water do not give a slurry of activated charcoal. Consider endoscopy to evaluate the extent of gastrointestinal-tract injury. If a large dose has been ingested and the patient's condition is evaluated within 30 minutes after ingestion, consider gastric lavage.


Antidotes and Other Treatments
Treatment consists of supportive measures.


Laboratory Tests
Routine laboratory studies for all exposed patients include CBC, glucose, and electrolyte determinations. Additional studies for patients exposed to an unidentified chemical include ECG monitoring, renal-function tests, and liver-function tests. Chest radiography and pulse oximetry (or ABG measurements) are recommended for severe inhalation exposure.


Disposition and Follow-up
Consider hospitalizing patients who have suspected serious exposures and persistent or progressive symptoms.


Delayed Effects
When the chemical has not been identified, the patient should be observed for an extended period or admitted to the hospital.


Patient Release
Asymptomatic patients who have minimal exposure, normal initial examinations, and no signs of toxicity after 6 to 8 hours of observation may be discharged with instructions to seek medical care promptly if symptoms develop.


Follow-up
Provide the patient with follow-up instructions to return to the emergency department or a private physician to reevaluate initial findings. Patients who have corneal injuries should be reexamined within 24 hours.


Reporting
If a work-related incident has occurred, you may be legally required to file a report; contact your state or local health department. Other persons may still be at risk in the setting where this incident occurred. If the incident occurred in the workplace, discussing it with company personnel may prevent future incidents. If a public health risk exists, notify your state or local health department or other responsible public agency. When appropriate, inform patients that they may request an evaluation of their workplace from OSHA or NIOSH. See Appendices III and IV for a list of agencies that may be of assistance.
Source:


ATSDR. "Medical Management Guidelines for Unidentified Chemical." ATSDR - MMG: Unidentified Chemical. Agency for Toxic Substances and Disease Registry. http://www.atsdr.cdc.gov/MHMI/mmg170.html.

Case Study: Chlorine

Sodium Chloride (table salt) is found in seawater and natural deposits, Sodium Chloride constitutes approximately 2% of the earth’s surface. Chlorine gas is generated by the electrolysis of aqueous sodium chloride. Chlorine gas is a noncombustible pale yellow-green, gas with a pungent, irritating odor. Chlorine is one of the ten most produced chemicals in the United States by weight. Chlorine gas is heavier than air and is categorized as a “choking agent”. Chlorine is a strong oxidizing agent and can react explosively or form explosive compounds with many other common materials. Chlorine is slightly soluble in water, but increases chlorine’s oxidizing and corrosive effects through the formation hypochlorous acid (HClO) and hydrochloric acid (HCl).
Chlorine has many applications: disinfectant (drinking water treatment facilities, wastewater purification systems, and swimming pools,); bleaching agents (paper and cloth); construction materials (polyvinyl chloride, or PVCs), computer silicon chips; pharmaceutical compounds (Singulair, Plavix, and Norvasc). Chlorine’s used widely as a chemical reagent in the synthesis and manufacture of metallic chlorides, chlorinated solvents, pesticides, polymers, synthetic rubbers, and refrigerants.


Use of Chlorine as a weapon was considered during the U.S. Civil War. The first documented use is April 22, 1915 during First World War, wherein Chlorine had a psychological shock effect, but proved to have limited military effectiveness due to changes in wind patterns available PPE for soldiers. Consequently, the use of Chlorine was abandoned in preference to other more effective chemicals (e.g. phosgene and mustard gas)


. The international legal community moved to outlaw the use of chemical weapons.


On January 28, 2007 Iraqi insurgent suicide bombers killed 16 people by detonating a truckload of explosives and a chlorine tank in the town of Ramadi in the al-Anbar province. Since then, insurgents have used vehicle borne IEDs containing chlorine on multiple occasions. Iraqi tactic changes demonstrate their flexibility and ability to adopt tactics that are successful. While these attacks have caused deaths, it is the explosion and not the chlorine that has proved to be lethal. Regardless, the efficacy of these attacks has increased as dispersion methods are improved.
Terrorist Advantages of Using Chemical Agents as WMDs
•        They are relatively inexpensive to produce.
•        The components are often cheap and easily accessible.
•        They are easy to use.
•        There are multiple means of delivery.
•        The fear factor. They can have a psychological as well as physical impact, causing pain for the victims and panic for the survivors.
•        Chlorine does not need to be chemically synthesized (given its abundance), and as a gas does not require active aerosolization for efficient dispersal.
•        A large release of chlorine may inflict mass casualties on unprepared civilians.
Terrorist Disadvantages of Using Chemical Agents as WMDs
•        There can be unpredictable consequences.
•        A terrorist group might not be able to effectively use them without causing harm to themselves.
•        There are often unpredictable effects.
•        Environmental conditions may cause the chemical agent to dissipate making it difficult to deliver a lethal dose.
•        chlorine is not nearly as potent a toxin as other chemical weapons used in terrorist attacks,
•        Relatively biological weapons require substantial finances, advanced equipment, appropriate chemical precursors, and personnel with specialized training in synthetic organic chemistry to prepare.


Meanwhile the US is examining its chemical infrastructure for vulnerabilities. It is believed that a deliberate release of 60,000 gallons of liquefied Chlorine in a highly populated area might result in between 10,000 and 17,500 deaths. The EPA estimates that there are approximately 15,000 facilities and 2,000 water systems in the US that which store more than the threshold quantities of hazardous chemicals necessary to trigger EPA regulation.
Chlorine, like all commodities, must be transported to market. It is estimated that approximately 12 million tons of is manufacture annually in the United States. Of which 90 ton pressurized railroad tankers move 3 million tons. Rail tankers are cost effective for large shipments. Railroad infrastructure (including trains, tracks, and stations) includes 171,000 miles of track. This provides a large window of vulnerability as there is no reasonable way to secure the entire US rail system.


Rubber or plastic PPE is effective dermal protection against Chlorine. APRs or PAPRs with appropriate cartridges or preferably SCBA or should be used by rescuers.


Risk for dermal absorption and ingestion is not high because Chlorine converts to a gas at room temperature. However, solutions such as sodium hypochlorite that can generate chlorine are corrosive and will damage skin and GI tract. Chlorine can also be converted to hypochlorous acid, which penetrates cells and reacts with cytoplasmic proteins which result in the destruction of cellular structures. Symptoms may be immediate or delayed. Victims should first be removed from the hot zone and then decontaminated by first removing all clothing, followed by flushing all skin, hair and eyes for 15 minutes or more and then washed with soap and water.


Because the pediatric population is closer to the ground (Chlorine is heavier than air), their airways are smaller (more surface area per ml of air), their increased minute ventilation is higher, and greater lung surface area to body weight ratio, in addition to their relative inability to self evacuate or self decontaminate they are more at risk than adults.


Because chlorine is water soluble, exposure to the gas irritates the mucous membranes and eyes at concentrations of less than 3 ppm. Moderate irritation of the upper respiratory tract occurs at 5-15 ppm, followed by chest pain, vomiting, and dyspnea at 30 ppm. Above 50 ppm, lung inflammation causes pulmonary edema followed by organ damage, and death secondary to cardiovascular collapse from lack of oxygen. Insufficient tissue oxygenation can produce acidosis. Chlorine is deadly at concentrations of several hundred ppm or higher. The IDLH for chlorine is 10 ppm. A 30 minute exposure at 430 ppm is lethal. Concentrations of 1000 ppm can be fatal within minutes.
There is no treatment for Chlorine exposures. Like many hazardous chemicals treatment is directed at supporting the ABCs.


The vulnerability of the transportation system and the potential effects that even a small release would have on the physical and psychological aspects of individuals and society suggest that education of the public should be done. This education should be directed at increasing awareness regarding appropriate courses of action (e.g. shelter in place) in the case of a chlorine release should be organized.


Chemical Terrorism Fact Sheet: Chlorine Chemical Overview; September 2002; Saint Louis University School of Public Health; https://erplan.net/WMD/ChemFiles/Links/ChemicalAgents/FactSheets/ChlorineFS.pdf


Richard Weitz; CHLORINE AS A TERRORIST WEAPON IN IRAQ; Hudson Institute, Ibrahim Al-Marashi – Koc University, and Khalid Hilal – Monterey Institute Center for Nonproliferation Studies; http://www.wmdinsights.com/I15/I15_ME1_Chlorine.htm


Benjamin H. Brodsky; Industrial Chemicals as Weapons: Chlorine; The James Martin Center for Nonproliferation Studies; July 31, 2007; http://www.nti.org/e_research/e3_89.html

Decontamination

Detail basic management procedures, including decontamination of a chemical agent attack on a health care facility.

A chemical event, whether it happened outside the hospital or where the hospital was the primary target would essentially be handled the same except within the hospital itself; adjustments would have to be made, since part of the hospital would be contaminated along with the personnel in contact with the agent.

Decontamination would have to be done internally along with on-going treatment in another area of the hospital, or moved to other facilities. If the contamination was confined to a portion of the hospital, the A/C and vacuum system would have to be shut down and the area closed. If the entire facilities was affected, as with a gas attack, the entire facilities would have to be evacuated and patients moved to another facilities and decontamination set up as described in the following discussion.

If the event was within the confines of the hospital then this would also present a security issue, since the perpetrator (s) may still be in the immediate area and could cause more problems unless identifies and apprehended. They could be planning a secondary attack so it probably would be better to evacuate the facilities and set up in another area.

Decontamination is the removal or reduction of chemical agents on an object or person. This may be done by physical means, chemical neutralization or detoxification. In the civilian sector it most probably would be by physical means, i.e. clothing removal and washing with soap/water or flour followed by wet tissue wipes.

Decontamination basically accomplishes two purposes: 1.Removes the contaminant from the person to prevent further damage. 2. Prevents chemical contamination of the hospital, therefore keeping the hospital “clean “for patient care.

Decontamination of chemical casualties is an enormous task. The process requires dedication of both a large number of personnel and a large amount of time. Even with appropriate planning and training, decontamination demands a significant amount of resources. The critical resources are PPE equipment, linen, multitude of staff to relieve on the various positions on the decontamination line, and security to protect the hospital and control the perimeter.

The most important and effective decontamination of any chemical exposure occurs within the first minute or two post-exposure. This is self- decontamination (probably not possible in the civilian sector). The military are trained in this procedure and have specific kits (M291) to accomplish this. In the civilian sector decontamination would have to be handled in the field by first responders or in a designated, equipped decontamination area near the treatment facilities or hospital. Because of the time frame it is almost impossible to do decontamination at the site of the event. By the time the first responders arrive and setup, those patients that can walk will self refer to the hospital and only the severely injured will be on-site for the first responders to treat.

I will assume that the first responders and hospital personnel have been trained in decontamination (hospital having had the FEMA course HERT) and have available equipment to accomplish this task when the event occurs.

The chemical used in the event could be pulmonary, cyanide, vesicants, nerve agents or incapacitating agents. The basic decontamination method for any of the above is irrigation with water and removal of clothing (removing clothing will in itself remove about 90-95% of contaminant). If the first responders arrive early on, a decontamination area, using two fire pumper trucks, can be set up parallel with tarp over the top to create a passage way, where patients can be directed and sprayed with water. This is not as good as if they were disrobed (which is not going to happen in the field) but it is better than nothing and will remove some of the contaminant.

Hopefully, the EMS system had practiced this scenario and have called the hospital and alerted them to the event and type of chemical, if known. The hospital should immediately lock down the facility, notify the HERT team, set up the preplanned decontamination protocol, and activate the HICS team’s CP with the necessary equipment.

The primary purpose of the decontamination at the hospital is to remove the contaminant from the patient prior to the patient entering the emergency room for treatment, thus keeping the hospital free from contamination (chemical).

All casualties coming to the hospital after a chemical event are assumed to be contaminated, even if decontaminated in the field, until certified to be ‘clean’ after passing through the decontamination tent. They are then checked by CAM (chemical agent monitor) and only if “clean” are they allowed into the ER. If found to still be contaminated they will be sent back through the decontamination line or spot cleaned and rechecked.

Of the possible chemicals used in a terrorist event, only vesicants and nerve gas might present a hazard problem within any open wound present on the patient.

The ideal decontamination set up at the hospital is listed in bullet format.

1. First responders to scene, decontaminating the patients with water, if possible. Assess the scene as to what happened, number of casualties, type symptoms, describe the event (fire, explosives, gas release, etc., inform the hospital what type injuries to expect), number of survivors and deaths, agent used, if possible, severity of injuries, and start triage. I assume the first responders will be fire, police and EMS, so the appropriate authorities will be notified and disaster plan put into effect.

2. Notify the hospitals as to findings in #1. Notify the command center and declare a MCI alert

3. Hospital locks down with security at each entrance; one controlled entrance for patients and one entrance for call- in staff.

4. CP set up in hospital. HICS operational–operations, planning, logistics, and finance/records.

5. The Safety Officer, a part of the command staff and reports to the IC, is a key player in the decontamination process. He should monitor the entire process to insure safety for the hospital personnel as well as the patients. He has the authority to stop or change any unsafe operations.

6. Hospital Emergency Response Team (HERT) activated and begins setting up decontamination equipment in the ER area, about 30 meters from the entrance.

7. Check the weather and set up decontamination tent downwind from ER entrance if possible.

8. Maintenance sets up traffic barriers to have one way entrance to ER. Egress routes established-one way in and one way out. Routes are needed for both vehicles and foot traffic.

9. Notify wrecker service (previously arranged by mutual agreement) to stand by to move any vehicle that blocks the roadway.

10. Perimeter established around hospital to keep on-lookers and the “worried well” outside the area.

11. Security (armed with live ammunition) where ambulances and people enter to check for weapons or explosives. (Hospital is good secondary target.) At this point have barriers arranged in a manner that patients will be funneled into the registration area. Ideally, the entrance where security is checking the patients and ambulances should be at least 50 meters from decontamination area.

The patients will then be triages into immediate, delayed (walking wounding), non ambulatory, and green (no decontamination needed). From here they will proceed to the disrobing area and segreated by gender.

12. The decontamination tent is set up about 30 meters from ER entrance. There will be three separate lanes through the tent.

· Patients with ALS needs. They will be taken immediately to a special room in ER for ALS care and decontamination

· Patients that can walk through the decontamination line and soap and wash themselves

· Non ambulatory patients that requiring direct assistance for decontamination by hospital personnel.

13. All personnel on the decontamination line would have PPE level C, which consist of:

· PAPR with loose fitting hood and appropriate filter cartiage.

· Full face shield

· Chemical resistant suit

· Waterproof, chemical-resistant boots.

14. At the decontamination entrance point there would be personnel to:

· Register patients

· Take all personal items from patients and secure with I.D. tags.

· Geiger counter to check for radiation

· All clothing removed, bagged and labeled “contaminated”

· All children under 6 Y.A. stay with mother regardless of sex. All above 6 years old go through the appropriate line.

· Ambulatory patients can use soap and water in showers

to wash, under the direction of hospital personnel.

· All non- ambulatory patients will be disrobed and placed on a conveyer line that will have six personnel to scrub bodies with soap and water along with pressure showers with a rate of one person/ seven (7) minutes.

· At the end of the decontamination line personnel will check each patient to assure decontamination is complete. This will be done with M-8 paper, M-9 tape and CAM (Chemical Agent Monitor). Placed in hospital gowns and if certified “clean” moved into the ER for treatment, and if not, spot cleaned or returned to the decontamination tent for re- showering.

· Although OSHA will give some leeway on disposal of contaminated waste water during an emergency, it is critical that the hospital develop decontamination and waste water containment plans.

· All reasonable measures must be taken by the hospital to capture waste water runoff.

15. As any time in the above process there is an ALS problem with the patient, it is taken care of at that time. If necessary, to address life threatening problems, transfer to an isolation unit in the ER for treatment.

16. The personnel on the decontamination line cannot stay in the PPEs, depending on the temperature, over 30-45 min. The planning section in CP should be setting up a relief schedule with the personnel for rotation on the decontamination line.

17. Logistics should be inventorying linen and if they do not have enough for the event start calling supplies since this is a “choke” point in the process.

18. At the entrance point it is always prudent to have a psychologist and/or social worker to meet the patients, and if necessary, address emotional problems with disrobing. (It is said “why would anyone complain about disrobing if the decontamination will save their life”. This is a flash point, when you separate families and you ask a wife to disrobe with her husband there. Be prepared address the problem or the line will stop there.)

19. If the chemical event happened in the hospital the same procedure for decontamination would take place but the facilities would have to be rearranged. The areas that were contaminated would have to be closed off or cleaned. The contaminated personnel would have to go through the decontamination line set up at the ER entrance.

20. If a patient has an imbedded object or an open wound, the area should be irrigated and covered with a marking to indicate imbedded object. Only a doctor should remove the object, either in the decontamination line or in the hospital.

21. When the event is declared over, the decontamination equipment and the decontamination area must be decontaminated and this is usually done from the clean area to the dirty area.

22. The event is not closed until all personnel in the HICS CP concur.

23. An AAR should be held at some point after the event.

clip_image002

24. Algorithm for Chemical Decontamination In a Hospital Setting. This setting can be changed to fit the geography of the hospital.

25.A recommended list of equipment for patient decontamination is attached:

· Staff PPE

Full face shield

Hood or hair covering

Gloves

Water repelling gown

Rubber boots

· Equipment list

Waterproof triage tags

Sealable plastic bags, size small & large to accommodate belongings and clothing

Paper bags

Labels

Permanent marker

Mild soap

Sponges

Long handle brushes

Buckets

Hoses with gentle flow, controlled nozzles with hot and cold water

Showers—multiple heads

Plastic pallets to prevent slippage (minimum of three)

Water contamination/collection system

Gowns and /or suits for patients to don post decontamination

Towels and blankets

Self Decon “trash bag” kits

Tents or pre-fabricated decon tents

Modesty screens, portable screens

Rope and tarps, barrier tape

Duct tape, scissors, traffic cones, megaphones, plastic totes for hospital equipment

Laminated decon instructions in different languages ( community specific)

References:

1).Medical Management of Chemical Casualties Handbook U.S. Army Medical Research Institute of Chemical Defense (USAMRICD) Aberdeen Proving Ground, MD. 3rd ed. 2000

2.) Textbook of Military Medicine: Medical Aspects of Chemical and Biological Warfare Office of Surgeon General 2005

3.) Hospital Emergency Response Team (HERT) FEMA Ft. McClellan, Ala. 2006

4. ) Hospital and Healthcare Systems Disaster Interest Group. Califormia Emergency Medical Services Authority 9/2004

www.emsa.ca.gov/dms2/recommendations.doc