Chapter 37
EMS Response to Terrorism
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© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Understanding Terrorism
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Terrorism
A violent act dangerous to human life,
to intimidate or coerce a government,
the civilian population, or any
segment thereof, in furtherance of
political or social objectives
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Domestic Terrorism
Directed at government or a
population, without foreign
direction
Often fragmented and leaderless
(cont.)
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Domestic Terrorism
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International Terrorism
Foreign based
Activities cross national
boundaries.
Often religious or politically
motivated
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Types of Terrorism
Chemical
Nuclear
Explosive
Weapons of
Mass
Destruction
Biological
Radiological
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September 11, 2001
© Corbis/Sygma
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
EMS Response
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Safety
Always remember that responders
may be targets of terrorism. Never
compromise your own safety during
an incident.
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Responder Safety
First Responders may be targets.
Consider the possibility of
secondary devices/events.
Utilize SOPs and protocols.
Never compromise your own safety.
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Responder Considerations
Identifying the possible threats
posed by the event
Recognizing the possible harms
posed by the event
Identifying protection measures
based on the possible threats and
harms
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Identify Threat Posed by the
Event
OTTO signs:
– Occupancy or location
– Type of event
– Timing of the event
– On-scene warning signs
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Occupancy/Location
Symbolic/historic targets:
– White House
– IRS offices
Public buildings and assembly
areas:
– Shopping malls
– Convention centers
(cont.)
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Occupancy/Location
Controversial businesses:
– Nuclear facilities
– Family-planning offices
Infrastructure systems:
– Power plants
– Hospitals
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Type of Event
Explosions/incendiaries
Incidents involving firearms
Non-trauma MCIs
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Timing of Event
National holidays
Anniversaries of other terrorist
events
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On-Scene Warning Signs
Unexplained patterns of illness
Chemical containers
Unusual items at locations
Fires with unusual behavior
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Recognize the Harms Posed
by the Threat
TRACEM-P:
Thermal harm
– Extreme heat or cold
Radiological harm
– Nuclear particles
(cont.)
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Recognize the Harms Posed
by the Threat
(cont.)
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Recognize the Harms Posed
by the Threat
TRACEM-P:
Asphyxiation
– Lack of oxygen in environment
Chemical harm
– Toxic or corrosive materials
(cont.)
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Recognize the Harms Posed
by the Threat
TRACEM-P:
Etiological harm
– Disease-causing organisms
Mechanical harm
– Physical trauma
(cont.)
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Recognize the Harms Posed
by the Threat
TRACEM-P:
Psychological harm
– Creation of fear and panic
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Possible Protection Measures
Time
Shielding
Distance
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Chemical Incidents
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Responses to Chemical
Incidents
Hazardous materials
Industrial waste
Warfare agents
(cont.)
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Responses to Chemical
Incidents
Materials may be:
– Inhaled
– Ingested
– Absorbed
– Injected
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Specific Types of Harm from
Chemical Incidents
Thermal
– Flammability/heat from reactions
Asphyxiation
– Reactions that displace oxygen
Chemical
– Cardiac, nervous, and respiratory
systems
(cont.)
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Specific Types of Harm from
Chemical Incidents
Mechanical
– Corrosives weaken structures
Psychological
– Emotional reaction to exposure
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Self-Protection at Chemical
Incidents
Be cautious of secondary devices.
Ensure victims are not the bombers.
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Biological Incidents
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Responses to Biological
Incidents
May be a focused emergency or a
public-health emergency
– Focused emergencies have a point of
origin, minimizing spread
(cont.)
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Responses to Biological
Incidents
Public health emergencies manifest
themselves as a sudden demand on
the public health infrastructure with
no apparent explanation.
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Causative Agents of Biological
Incidents
Bacteria
Toxins
Viruses
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Exposure
The dose or concentration multiplied
by time (duration of exposure)
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Four Biological Agent Routes
of Entry
1. Absorption
Skin contact
2. Ingestion
Through mouth
(cont.)
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Four Biological Agent Routes
of Entry
3. Injection
Needles or projectiles
4. Inhalation
By breathing
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Contamination
Contact with or presence of a
contaminant, which is material that is
present where it does not belong and
that is somehow harmful to persons,
animals, or the environment
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Exposure vs. Contamination
Exposure
– Substance enters body through one
of the routes of exposure.
Contamination
– Substance clings to body or
clothing.
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Specific Types of Harm
from Biological Incidents
Etiological
– Poisonous hazardous materials
Chemical
– Secondary events
(cont.)
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Specific Types of Harm
from Biological Incidents
Mechanical
– Secondary events
Psychological
– Emotional reaction to exposure
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Self-Protection at Biological
Incidents
Use personal protective
equipment.
Limit exposure time.
Use buddy system/rapid
intervention team.
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Radiological Incidents
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Responses to Radiological
Incidents
Unlikely to occur
May be in the form of an explosive
device
Difficult to initially detect
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Specific Types of Harm
from Radiological Incidents
Thermal
– Nuclear explosion
Radiological
– Ongoing, varies with substance
Chemical
– Many substances are also chemical
hazards
(cont.)
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Specific Types of Harm
from Radiological Incidents
Mechanical
– Nuclear explosion
Psychological
– Emotional reaction to exposure
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Self-Protection at Radiological
Incidents
Use time/distance/shielding.
Use decontamination procedures.
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Explosive Incidents
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Responses to Explosive
Incidents
Vary in size from pipe bombs to car
bombs
May have suicide bombers
May contain chemical or biological
agents
Most frequent weapon used by
terrorists
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Specific Types of Harm
from Explosive Incidents
Thermal
– Heat from detonation
Asphyxiation
– Dusty conditions
Chemical and radiological
– If present in the device
(cont.)
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Specific Types of Harm
from Explosive Incidents
Mechanical
– Shockwaves and fragmentation
Etiological
– If biological agents present
Psychological
– Stunned response
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Self-Protection at Explosive
Incidents
Be cautious of secondary
devices.
Ensure victims are not the
bombers.
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Dissemination of Agents
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Methods of Dissemination
of Agents
Respiratory/inhalation
– Most effective method
Ingestion
– Effectiveness
Dermal
– Some agents effective this way;
others prevented by logistics/
immunization
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Weaponization
Use of
sprayers to
disseminate
Use of explosives
to disseminate
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Dissemination of Agents
© Neville Elder/Corbis Sygma
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Chemical Agent Considerations
Physical considerations
– Extremely varied
Volatility
– May evaporate quickly
(cont.)
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Chemical Agent Considerations
Chemical
– Reactivity and stability vary
Toxicological
– Variety of factors influence sensitivity
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Classification of Chemical
Agents
Choking agents
Vesicating agents (blister agents)
Cyanide
Nerve agents
Riot-control agents
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Classification of Biological
Agents
Bacterium
– Can live outside host cell
Virus
– Cannot survive outside of host cell
Toxin
– Poisonous chemical compound
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Biological Agent Weapon
Considerations
Infectivity
– Virulence
– Toxicity
– Incubation period
– Transmissibility
– Lethality
– Stability
(cont.)
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Biological Agent Weapon
Considerations
Transmissibility
Lethality
Stability
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Classification of Biological
Agents
Infectivity
– Ease in invading host cell
Virulence
– Severity of disease produced
Toxicity
– Severity of illness from toxin
(cont.)
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Classification of Biological
Agents
Incubation period
– Time between exposure and
symptoms
Transmissibility
– Ease of passing from person to
person
(cont.)
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Classification of Biological
Agents
Lethality
– Ease in causing death
Stability
– Viability to outside influences
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Biological Weapons
Bacteria
– Single cells, don’t require a host
– Easy to grow and spread
Anthrax
– Naturally occurring
– Inhalation is greatest concern.
– Early treatment with antibiotics is key.
(cont.)
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Biological Weapons
Cholera
– Diarrheal disease
– Treat dehydration.
Plague
– Transmitted by fleas
– Can be highly contagious
– Use respiratory precautions.
(cont.)
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Biological Weapons
Q fever
– Similar to anthrax
– Treat with antibiotics.
Tularemia
– Usually from bites of animals
– Fever, headache, weight loss
– Treat with antibiotics.
(cont.)
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Biological Weapons
Staphylococcal Enterotoxin B
(SEB)
– Similar to food poisoning
– Treatment is supportive.
Trichothecene Mycotoxins (T2)
– Death within 12 hours
– No vaccine
– Treat symptoms.
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Toxin Weapons
Do not aerosolize on their own
Do not reproduce
Do not transmit person to person
Generally, intact skin is an effective
barrier.
(cont.)
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Toxin Weapons
Botulism
– One of the deadliest compounds
Ricin
– Easy to make; common weapon
– Interrupts cell processes; causes
death
– Most effective through inhalation
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Virus Weapons
Simplest microorganisms
Require a host cell
Not easy to manufacture
(cont.)
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Virus Weapons
Smallpox
– Thought to be eradicated, but may
exist
– Highly contagious
– Spread by respiratory droplets
Encephalitis
– Naturally occurring
– Inflammation of the brain
– More incapacitating than lethal
(cont.)
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Virus Weapons
Viral Hemorrhagic Fever (VHFs)
– Ebola, Dengue Fever, Yellow Fever
– Changes the clotting ability of blood
– Highly contagious and lethal
– Liquefies internal organs
– No vaccines or cures
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Radioactive/Nuclear Weapons
Military/sabotage
– Highly unlikely
Improvised
– Easy to gather knowledge;
implementation very difficult
“Dirty bomb”
– Similar issues as improvised device
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Incendiary Weapons
More plausible by using:
– Molotov cocktails
– Propane bombs
– Shaped charges
– May disseminate other weapons
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Strategy and Tactics
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Strategy and Tactics
Strategies
– Broad plans
Isolation
Tactics
– Specific
methods to
achieve them
Protection
Notification
Identification
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Isolation—Initial Considerations
Determine severity of danger.
Control the scene and size it up.
Isolate the hazard area.
Attempt to evacuate (based on
hazards).
Establish perimeter control.
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Isolation—Perimeter Control
May be difficult based on
resources
Overestimate the size of the
perimeter.
(cont.)
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Isolation—Perimeter Control
Outer perimeter
– Most distant boundary line
– Restrict all public access beyond it.
Inner perimeter
– Isolates known hazards inside the
outer perimeter
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Perimeter Control Factors
Availability of resources
Size and configuration of incident
Stability of the incident
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Notification
Notify federal and state support
agencies during a suspected or known
terrorist event (usually done by
dispatch centers).
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Identification
May or may not be possible
Do not endanger yourself to
determine.
Report obvious signs or indicators.
Note placards and labels.
Use the Emergency Response
Guidebook.
Report unusual patterns of illness.
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Protection
EMTs are responsible for protecting
themselves and their people:
– Perform an initial scene survey.
– Request security (police/military).
– Establish vehicle staging and
treatment areas.
– Advise EMS command of concerns,
suspicious people, and/or activities
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© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Review Questions
1. List and briefly describe the five
most common types of terrorism
incidents.
2. What is a secondary device? What
precautions should be taken by an
EMT regarding secondary devices?
(cont.)
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© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Review Questions
3. List several types of events that
should trigger an EMT’s suspicion
of possible terrorism involvement.
4. List the seven types of harm that
result from a terrorism incident—
and the seven-letter acronym for
these types of harm.
(cont.)
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Review Questions
5. Briefly discuss the concept of time,
distance, and shielding.
6. Discuss several self-protection
measures for biological incidents.
7. Discuss the tactics for isolation,
notification, identification, and
protection.
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Street Scenes
What are the indicators that this is a
suspicious incident?
What steps should be taken to isolate
the area?
(cont.)
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Street Scenes
What steps should be taken to
identify a possible mechanism of
injury?
Identify the critical personal
protection issues on this scene.
(cont.)
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Street Scenes
What are the indicators that this may
be a suspicious incident?
What protection precautions should
be initiated—and by whom?
(cont.)
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Street Scenes
Discuss the proper notification
procedures. What support agencies
are required on this scene?
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© 2009 by Pearson Education, Inc., Upper Saddle River, NJ