By STEVE KANARIAN
Awareness training teaches emergency responders that terrorist incidents are more likely to occur during daytime hours, on the anniversaries of prior terrorist attacks, in government buildings, and in places of worship. During the month of April, we remember the Columbine High School massacre and the Murrah Federal Building bombing in Oklahoma City. Especially in the post-9/11 world, emergency responders must maintain a high degree of suspicion and awareness of prominent dates, high-profile locations, and potential secondary events. Safe operations require adoption of an all-hazards safety approach to responses involving explosions, multiple patient calls, and other unusual circumstances.
When we respond to a mass casualty incident (MCI), we must make two main adjustments in our response mind-set to prepare for terrorism. Terror organizations’ intent is to cause damage and kill civilians and rescuers to gain publicity for their cause. In the past, these incidents were dangerous; in the present, terrorist incidents are lethal.
WE ARE THE TARGET
Identifying an MCI cause is fruitless. The Oklahoma City (OK) Fire Department thought it was responding to a gas explosion on April 19, 1994. Firefighters responding to the World Trade Center in 1993 believed the incident was a transformer fire. In both cases, the event’s terrorist origin was not apparent until the smoke cleared and an explosive crater was discovered.
Contrarily, the airplane that New York Yankees pitcher Cory Lidle accidentally crashed into a Manhattan high-rise building in October 2006 was immediately suspected as terrorism. When we respond to a high-risk incident, we must follow an all-hazards approach and not attempt to guess the MCI’s cause. Responding fire companies should focus safety concerns on hazards and reevaluate the evolving scene for secondary incidents; use general safety rules on all responses. By embedding safety procedures in our daily operations, we can develop safety habits that will pay off during a terrorist incident.
SCENE SIZE-UP
A good safety practice when responding to any incident is to stop at the outermost perimeter of the call location (or when you can first see the building) and scan for key terrorism indicators. Stop, look, listen, think, and listen to your instincts. Allow time for your brain to assess hazards and process scene information. Scene assessment begins with a review of the dispatch information. Outward indicators of terrorism include chemical clouds, dispersal equipment, weapons, and gas containers. Know your response area so that you can recognize anything that looks out of place or deviates from routine.
Scenario: “Engine 35, Medic 1: Respond to Elmwood High School for difficulty breathing.”
As you respond to this call, Dispatch updates your call information: “Engine 35, Medic 1: You have three patients with shortness of breath and vomiting.” Realizing this response is different from the usual asthmatic in the nurse’s office, you stop the apparatus as you turn the corner to approach the school. On-scene, you observe two police officers coughing and rubbing their eyes and several students who appear short of breath and vomiting on the sidewalk. Your scene size-up warns you that this is a potential SLUDGEMS (salivation, lacrimation, urination, defecation, gastrointestinal upset, emesis, miosis) incident requiring isolation suits and decontamination. Proper scene size-up prepares you for the appropriate response and to not expose members to chemicals without adequate protection.
A word of caution: Terrorist organizations use an initial event to injure civilians and draw in emergency responders. This tactic was clearly demonstrated in the fictional movie The Kingdom, starring Jamie Foxx. (I highly recommended this video for use in training sessions or to gain perspective on secondary events.) You must consider clearing a scene of weapons, perpetrators, and explosives prior to initiating search and rescue to reduce the risk of injuries and deaths from a secondary event. The school scenario mentioned here may have been designed to lure emergency crews to an event with multiple secondary devices. Law enforcement will not stand by when active danger to citizens or responders exists. Tactical teams composed of specially trained firefighters/paramedics accompanied by heavily armed and armored law enforcement officers may deploy to make immediate rescue while providing lifesaving treatment to victims who otherwise would not survive without treatment until the scene was completely safe.
The magnitude of the Murrah Federal Building, the World Trade Center, and the Madrid train bombings demonstrates an increasing mortality and severity of terrorist incidents. To date, explosives are the most common weapon terrorists use; casualty numbers could increase exponentially with the use of chemical and biological weapons. Continually drill on plans to implement rapid decontamination, and use proper protective equipment.
All emergency responders need to improve knowledge and response methods in expectation of the future. As experienced responders retire from the emergency services, familiarity with terrorism is rapidly decreasing. Newer firefighters should be especially diligent in observing the scene size-up, evaluating hazards, suspecting the secondary event, and heeding the lessons learned from past incidents.
PREPARING FOR THE UNKNOWN
You can prepare for future incidents by following safety rules daily, incorporating best practices, and training. The most basic safety rule is “time, distance, and shielding.” Minimize your exposure time to a hazard, maximize your distance, and use the best shielding available to maximize safety. When you operate at a terror-related event with secondary devices, communicate with law enforcement and seek hard cover (protection that can stop bullets and projectiles). Protection behind buildings, concrete walls, and similar obstructions is optimal cover; standing behind vehicle doors and wood structures is not. Participation in response to terrorist acts in progress requires fire and EMS to seek cover and minimize potential exposure by working with law enforcement.
Some rules to live and stay alive by follow:
- Stay upwind and upgrade from fumes and liquids.
- Maintain a 1,500-foot distance for explosive devices and incidents.
- Prohibit radio and cell phone transmissions at bomb incidents.
- If you can see a hazmat incident when holding your thumb up, you are too close.
- In partially devastated buildings; be aware of secondary devices/explosives.
- Maintain a distance of at least two to three times the building’s height during prolonged fires or buildings damaged in explosions.
- Vary response routes and routine operational tactics.
LESSONS LEARNED
Events at two terrorist incidents detail the criticism of EMS personnel rushing to the scene while the incidents were still unfolding. At Columbine High School, medics were criticized for not waiting for the scene to be determined safe. During the Columbine response, medics entered the school ground to assist severely injured patients. By entering an active scene of an ultraviolent incident, these paramedics placed themselves in grave danger to rescue injured patients. The concept was correct: maximize lives saved by providing early treatment of life threats. Responders should have conducted implementation under the cover and armor of trained law enforcement officers.
After the Atlanta Olympic Park bombing in 1996, Atlanta (GA) Fire Department Assistant Chief Don Heitt Jr. said, “When medics see patients, they have a tendency to forget the number one rule [safety].”1 EMS providers were again criticized for engaging patients before the scene was checked for secondary devices or perpetrators; a secondary device was ignited but did not fully detonate.
Although these two incidents did not result in emergency responder injury, the potential for injury or death was present at both events. Careful coordination with law enforcement is essential before entering any potentially hostile scene; this does not happen at the time of arrival—it is established, practiced, and drilled repeatedly so that no mistakes are made when the time comes to put it in place.
A more poignant example of the consequences of terrorist incidents occurred during the Tokyo subway system attack involving the release of sarin nerve agent gas. As hundreds of civilians were overcome, 135 emergency medical technicians (9.4 percent of total patients) were secondarily exposed to sarin. Okamura points out that the sarin used was only 30 percent of its strength. Full-strength military sarin could have resulted in EMT and paramedic deaths.2 Ventilating the ambulances and treatment areas alleviated secondary exposure.
LESSONS LEARNED FROM OTHER COUNTRIES
The Northern Ireland Fire Department uses tactics to minimize personnel exposure to secondary events: “They always handle incidents with the minimum of resources and deploy backups to nearby stations. They can have also learned to routinely remove victims to safety and are aware that attacks can include multiple incidents.”3 The London (UK) Fire Brigade (LFB) uses perimeters to control the scene and enforce safety when dealing with potential terrorist incidents. “Two concentric areas are established—the inner cordon and the outer cordon. An outer cordon is established to limit the incident from affecting nearby businesses and homes. An inner cordon is also established to monitor and control crews working at the scene.”(3) This use of perimeters allows the LFB to control personnel entering and exiting and accountability. The LFB uses the inner perimeter to brief crews about safety concerns before entering and debrief them when exiting the inner cordon.
TRAINING
To understand the evolving nature of terrorism, fire departments should progressively train and think outside the box. What does decent terrorism training look like? Preevent training should address multihazard scenes and the need to communicate among fire departments, police departments, and EMS. If we train emergency responders to stage and wait for the scene to be cleared of perpetrators and bombs and set up decontamination, we can prevent secondary illness and injury from unnecessary exposure. In some situations, this approach may offer too little too late. More recently, prearranged and well-drilled tactical teams using firefighter medics or other EMS personnel coupled with highly skilled police tactical officers can secure perimeters, lock down areas, and maximize saved lives with early intervention.
During a terrorist incident, responders’ adaptation and problem solving will carry the day. Rescue personnel should seek out as much varied training and knowledge as they can. Scenarios staged in fire training academies should incorporate hazards requiring police and fire specialty units; communication between services will save lives in a major terrorist incident. Frankly, if emergency responders are not trained to stage and wait for a scene to be cleared of explosives, perpetrators, or decontamination setup, they run the risk of large-scale fire department personnel injuries and fatalities. Stage scenarios using real hazards and challenge responders to incorporate children and public employees as patients.
Emergency responders trained using realistic scenarios will be more likely to survive a future terrorist incident. This may require hard decisions; address these ethical and operational issues in tabletop sessions and drills. Emergency responders tend to perform as they have trained. Now is the time to prepare for the challenges of the future, known and unknown, by incorporating past lessons.
ENDNOTES
1. Nordberg, M. “Terror at the Olympics.” EMS Magazine, 25(11) 51-57 (1996).
2. Okamura, T., N. Takasu, S. Ishimatsu, et al. “Report on 640 victims of the Tokyo subway sarin attack.” Annals of Emergency Medicine, (28), 129-135 (1996).
3. Buck, G. Preparing for terrorism, an emergency services guide. Albany, New York: Delmar Publishing (2002).
STEVE KANARIAN, BS, MPH, paramedic, is the lead instructor of the City University of New York—LaGuardia Community College Paramedic Program. He is a retired lieutenant in the Fire Department of New York EMS Command who responded to both World Trade Center attacks.
