The events of Sept. 11, 2001, and the incidents following that terrible day have brought our country to a point where all communities must plan for their responses to these and other types of terrorism. The focus of the planning must change to a more practical way of addressing the concerns of the fire service and other public safety agencies.
There is no way anyone could remotely predict what happened in New York on that horrible day. The initial response was to a typical high-rise fire. Command posts were set up like they always were, and the brave firefighters who lost their lives responded just like they were trained to do.
This event, of course, became a mass-casualty incident (MCI) of a magnitude never seen in this country. Thousands of victims were killed and injured. In the following days, and weeks, many anthrax incidents literally closed down government offices and private-sector businesses.
Because of panic and an unfamiliarity in dealing with terrorism, especially involving biological and chemical events, hazardous materials teams and for that matter all fire departments were inundated with suspicious-powder calls that depleted the resources of even larger fire departments. Here in Miami, from Sept. 12 to Oct. 12, the City of Miami Fire Department responded to 2,700 suspicious calls. Some of these were credible threats, but most were just hysteria. The end result was the same - a depletion of usable resources in a short amount of time. Decontamination procedures never used in the past were not only time consuming, but equipment and manpower intensive as well.
I had the pleasure of attending a seminar on this very subject sponsored by the police department and other county agencies that was given by Dr. Henry J. Siegelson, MD, FACEP, of Disaster Planning International in Atlanta, who extensively covered the subject of community preparedness and response to the terrorist event. Some of the concepts mentioned here will be from that seminar. Siegelson looked at the whole community and stressed that a response to this type of event is not just the fire department and hospitals, but the community at large.
To plan for a terrorist event, the main concern is to focus on the plan, not the threat. In other words, a general plan should be formulated on how we will respond to ANY threat, not just a World Trade Center or anthrax type of incident. Most importantly, an MCI response should be the focal point of any response. This takes into consideration a potential large loss of life, and subsequent injuries as well. It encompasses the hospital response as well as the public safety response, and most importantly the complete community response.
Plan For The "Big One"
As a starting point we should look at the reaction to a terrorist event from all angles:
1. Psychology before the disaster. Until Sept. 11, 2001, and probably several months from now, a false sense of security will set in. "It won't ever happen again" will be the new thought as we get comfortable with a renewed sense of invulnerability. Another predominant thought is, "It won't happen to me." We have all seen this when fire departments ask for increases in their budgets, and the people say to themselves, "I won't have a fire in my house, I am too careful." Lastly, the thought will be, "It won't be that bad if it happens." But no one could imagined that four large jets would be hijacked and crashed into large important buildings. Even the Pentagon, the bastion of our national defense, was struck.
Now is the time to plan for the "big one," because it will happen again. It is not "if," it is just "when."
2. Psychology after the disaster. After the disaster, we concentrate on the attack itself - and like most humans, we close the barn door after the horse is gone. The concentration is how to prevent the attack and not how to address a new threat. We must look at the type of event in a new perspective, a "generic" threat potential.
A good way to start this process is to evaluate the threat potential in your community. Fire and police should meet collectively to check possible target hazards. All agencies should be involved. Fire department battalions can divide up into inspection territories and examine possible threat potentials. Fire prevention personnel, public service aides and other agencies can canvass the community and list what they think are possible threats. Building departments can look at their files and provide assistance to the above-named departments . Tax records can be used to search for potential targets. The indirect effect of this is a better familiarization of buildings and their inherent problems from a fire perspective.
Areas of concern should be municipal government buildings, chemical storage facilities, federal buildings, hospitals, power plants (especially nuclear), laboratories or biological research facilities, and places that store explosives. Military bases and National Guard armories should be examined as well.
Once a building or facility has been identified, certain information should be gathered. Are there any hazardous materials on the premises and where are they? Where are the air handling unit controls? Are there fire protection devices in place? Where are the entrance and exits to the facility? Are any ancillary security measures in place? What is the potential for life and property loss should something occur? What additional resources might be needed?
Once these facilities have been identified, plans should be formulated on how a response would be handled. Fire and police would be the main focus to initial response, but what is to be done for the many victims? The dead?
Of course, the usual response would be the hospitals. This is the logical answer, but if you throw the term hazardous materials victim, the equation drastically changes. Most hospitals want nothing at all to do with chemical contaminated or exposed victims. The majority of the hospitals in the Miami area have flatly said they would refuse any chemical exposed patients. That is a pretty bold statement if all of a sudden there are hundreds and possibly thousands of victims.
The reality is that the wealth would be shared by all hospitals in spite of their stated position. What will happen is that all victims will be sent to available hospitals, and police and fire units will respond to those emergency departments as well. Once there, they will attempt to control an orderly decontamination of all victims before they enter the hospital emergency department.
On the scene of an incident, it goes without saying that no paramedic or EMT should allow a contaminated victim to enter an ambulance unless decontamination has been completed. Recognize, however, that there will be a reluctance to remove one's clothes, especially among people who are asymptomatic.
Decontamination Priorities
On the scene of an incident the control of hundreds or thousands of panic-stricken victims is a pipe dream. They will all be running in all directions. There should be an orderly or at least a planned attempt to orderly triage these victims and decontaminate these people. Siegelson talks about a system of "adult triage." In this system several firefighters and or paramedics in at a minimum of Level B protection with respiratory devices in place will observe people exiting a facility or site and prioritize them into three categories. Decontamination of victims must be done quickly and immediately.
Priority 1: Non-ambulatory victims who have been exposed to product and presenting signs, symptoms and associated other injuries. Requires immediate removal of clothing and immediate access to shower, preferably soap and warm water, if possible.
Priority 2: Ambulatory, but presenting minimal or no signs or symptoms. These people can walk and talk, but were exposed to the product or were very near the product itself. Requires immediate dry decontamination (removal of clothing and donning paper gowns) to await decontamination shower. Send to secondary assessment center, if possible. If shower is available in building, they should use those facilities. Advised to use soap and warm water, if possible. If not, they should wait their turn behind Priority 1 patients. (In all honesty, these people will seek their own showers and will not wait.)
Priority 3: These patients will think they might have been exposed. These patients are called the "willing walking." They will present no signs or symptoms, will have no physical distress, and are just concerned people who will become the lowest of the priorities. They require dry decontamination. They should be given a paper gown and advised to disrobe and await their turn in the decontamination shower line. This will be the bulk of the presenting victims. These people will become impatient and will go home and shower there. They will almost all be perfectly fine. Priority 2 and 3 can seek other means of showering, including home or other secondary facilities in place. In categorizing these victims, secondary assessment centers (SACs) are identified as gymnasiums, auditoriums and facilities that have showers in place.
Making Tough Decisions
Considerations for on-scene operations are:
- Not all victims are viable. Those who have a viable chance to survive should receive priority.
- If a nerve gas is used and victims are symptomatic, the Mark 1 antidote kit should be administered within one to three minutes.
- Hard decisions will have to be made and extreme procedures followed in order to save as many people as possible. Triage of victims will take on new parameters. Instead of treating the worst cases first, those who are the most viable will be the ones prioritized in the red or critical first. Those who have no chance of surviving, i.e., cardiac arrest victims, must be tagged in the black or dead. This is almost the opposite of what is done during normal EMS operations, but there just isn't enough manpower or resources, with such large numbers of victims.
Since we have seen first hand how devastating a terrorist event can be, the time to plan for the next one is now. As stated before, it should be a community effort involving all resources. Logistics will be a nightmare and plans should be in place to store or at least procure on any emergency basis expandable items such as food for the rescuers, privacy kits for victims, additional Level B chemical suits, extra air bottles or masks, and additional resources from the local office of emergency management.
Proper documentation is paramount to properly track victims - where they were transported and other pertinent information. The health department will have to be actively involved in this process, and will become even more important if it is believed a biological weapon could have been used. Laptop computers will be invaluable in this documentation. Information such as signs and symptoms, how long they have been manifesting and where the victim has been recently will be items worth documenting. Because this information will be used primarily by the health department and eventually by U.S. Centers for Disease Control and Prevention (CDC), perhaps the forms should be designed so it can be used most efficiently.
Experience here in Miami has shown that of all the agencies that are needed to coordinate a planning strategy, the health department has been the most reluctant to attend planning meetings, and this agency by far is one of the most important.
In summary, the planning for these incidents should be a team effort with all participating agencies providing feedback and information. Most importantly, the planning should begin now, so we will be ready when the next event happens, and make no mistake, it will happen again.
Chief Concerns is a forum addressing issues of interest to chief fire officers. Opinions expressed are those of the writer. We invite all volunteer and career chief fire officers to share their concerns, experiences and views in this column. Please submit articles to Chief Concerns, Firehouse Magazine, 445 Broad Hollow Road, Melville, NY 11747.
Tactical Medics: Is There A Need?
In 1979, the City of Miami initiated its first tactical medic team (SWAT-Medic), one of the first fire-based tactical medic systems in the country. This was a very bold step forward, I like to think, that employed paramedic skills and the experience of the fire department, and combined that effort with the special weapons and tactics (SWAT) team of the Miami Police Department.
Today, Miami's tactical medic team survives, along with many others around the globe. It has not been easy, however, and traditional fire chiefs still do not support this program. In the years I have been with this program, I have had to justify its existence with every new fire chief who has been in office. There are many reasons for this duplication of effort.
This is a concept that goes against the grain of most fire chiefs. The comments I have heard include, "Why do the paramedics carry firearms? That is not their job." My usual reply is that the job of the firefighter/paramedic is to save lives and property, and this is just an extension of that credo. Granted, the risks are different - and there are risks, of course. There are risks also every time a firefighter enters a burning building, treats a patient who has a communicable disease, or rescues a person from a tall building or the ravages of a wildfire. The difference is that the tactical medic knows there are criminals out there who are armed, and that they will shoot you if they can.
It is important to understand what tactical medics do and their theater of operation. Their job is to provide medical support for police officers and civilians, and in some cases to the criminal involved in SWAT team operations. They are not considered part of the direct-assault force. They will, however, in most cases be part of the team making entry into a hostile environment, but do not use deadly force unless they are threatened, or a police officer or civilian is threatened by a criminal.
Part of the basic training of a tactical medic is the use of deadly force. This is reviewed several times a year, and every time the medic must qualify with the weapons he or she carries. This is very important, since most of the medics are not police officers and have no arrest powers. (Under a state statute, a police officer who sees the need for immediate assistance can deputize another person.)
I have had to address this issue at least a half dozen times in the past 15 years. Finally, after much pleading, the city attorney has stated that as long as the tactical medics are working under the direct authority of the police department, it is legal for them to carry firearms, if they are trained in deadly forcer and the use of the said firearms. Since we now have that on record, this issue has finally been to rest.
Another way of looking at this is, what potential for liability exists if tactical medics are placed in harm's way without the ability to defend themselves? This, of course, places a severe financial risk to the municipality that refuses to arm its tactical medics. There are several teams out there that operate that way. Probably the best way to address this issue is to certify all tactical medics who are firefighters as reserve or auxiliary police officers. These classes are given at most police academies at night and on weekends. Training can take from five weeks to nine months, depending on the certification sought.
Part of the problem of accepting the tactical medic concept involves unions - some embrace the concept, others do not. The International Tactical EMS Association, based in Farmington, MI, has attempted to organize tactical medics around the world and has taken a step in the right direction. The organization offers a wealth of information from its members. It also has held three annual conferences and all of them have been excellent and well worth attending. Further information is available by e-mail at [email protected].
It appears as though the need for this type of fire-based service is ever increasing, and in this writer's opinion those that have the ability to provide it and elect not to do so could be placing their municipality in a potentially volatile situation. The tactical medic concept is endorsed by the National Tactical Offers Association as well.
In the years since the Miami SWAT Medic Team's was created, only four new classes have been given. The attrition rate is literally nonexistent. In fact, I think I am the oldest living tactical medic on the planet. Whenever volunteers are sought for new classes, the response is overwhelming, and we usually have to turn people away. Most police tactical teams also like the concept because it adds a new element of protection for those officers.
Another question often presented is, why not train police officers as paramedics? This can certainly be done, but logistically how does a full-time police officer attend some 1,000 hours of medical training, not including emergency department time and riding an ambulance for a minimum of 160 hours? Most importantly, where will they obtain hands-on treatment experience?
Actually, it is easier and our experience shows that training a firefighter/paramedic in basic police SWAT tactics and team movements is much easier. Those medics also have ongoing experience in treating all kinds of traumatic wounds and understand the physiology of an injured person much better.
I know that several teams have police officers trained as paramedics. I also know that some teams have physicians who are certified reserve police officers and are considered operators on SWAT missions. Unfortunately, not all teams have that luxury.
In today's ever-increasingly violent society and the constant threat of domestic terrorism increasing, the tactical medic is here to stay as an important extension of the fire service.
—Michael J. Essex
Chief Michael J. Essex is the special operations officer assigned to Emergency Response Division of the City of Miami Fire Rescue Department. He is a member of the hazardous materials and dive rescue teams and is a SWAT-Medic commander.
