Bioterrorism Preparedness and Response for Healthcare Professionals




EMS Star of Life

Wild Iris Medical Education is an approved provider for paramedic and EMT continuing education in California by the Coastal Valleys EMS Agency: CE Provider #49-0057.

This course is appropriate for EMTs, paramedics, and first responders.

Course Availability: Expires October 1, 2015. You must score 70% or better on the test and complete the course evaluation to earn a certificate of completion for this CE activity. Wild Iris Medical Education, Inc. provides educational activities that are free from bias. The information provided in this course is to be used for educational purposes only. It is not intended as a substitute for professional health care.  Medical Disclaimer   Legal Disclaimer   Disclosures

Bioterrorism Education and Preparedness for Healthcare Professionals

COURSE OBJECTIVE:  The purpose of this course is to inform healthcare professionals about how to prepare for and respond effectively to an act of bioterrorism involving biological, chemical, and nuclear weapons, methods to protect themselves and patients, and the role of the Health Alert Network.


Upon completion of this course, you will be able to:

  • Define “terrorism” and distinguish it from a criminal act and a mass casualty incident.
  • Define “weapons of mass destruction” (WMD) and list the five general types.
  • Describe signs and symptoms indicating possible exposure to common biological, chemical, and nuclear agents.
  • Discuss current treatment methods, syndromic surveillance, and reporting procedures for acts of terrorism.
  • List appropriate personal protective equipment (PPE) for healthcare workers treating patients potentially or actually exposed to biological, chemical, and nuclear agents.
  • Discuss vicarious trauma, including personal strategies to cope with it.
  • Identify steps for appropriate personal and facility preparedness for biological, chemical, and nuclear terrorist acts.
  • Explain the Health Alert Network (HAN).


Violence and warfare as means for one nation, state, or group to achieve control over another are almost as old as humanity. Records of wars survive in legends and oral traditions, and some of man’s earliest efforts at pictorial or language-based records deal with battles.

Records would indicate that for a long time wars were conducted primarily by and against other military forces using military means. Intentional infliction of direct casualties on civilians was considered inappropriate, or at least reserved for last-case situations. Similarly, civilian targets were not usually attacked for their own sake, but only if they had tactical or strategic value.

Advances in weaponry were focused in improving existing conventional technologies. It was only after chemical weapons as such were introduced in the trenches of World War I that widespread attention was directed to what would be termed “unconventional weapons.” Even so, the use of such weapons was, at least in the mind of the American general public, restricted to some remote battlefield.

This worldview changed for some nations before it did in the United States. But the images seared into our brains of the Murrah Federal Building in Oklahoma City in 1995, the September 11 attacks on the World Trade Center and the Pentagon, and the crash site of United Airlines Flight 93 have forced us to confront the reality that we as a nation and as individuals are potential targets.

It could be paralyzing to realize that no one is absolutely safe and no place is off limits as a target for those who seek to advance their agenda by fear. But it would be equally counterproductive to deny the threat and do nothing to prepare for such an eventuality, as a healthcare provider or healthcare facility.


To begin to respond effectively to acts of terrorism, it is crucial to have a clear understanding of what they are. One difficulty is that words and phrases with strong emotional overtones may be used primarily for their ability to engage an audience. Words with the root terror may be used incorrectly or overused to the point that their actual meaning is lost to the listener or reader. Professional literature, especially that which is peer-reviewed, can be a more objective source than popular media.

What Is and Is Not Terrorism?

The Federal Emergency Management Agency (FEMA) describes terrorism as “the use of force or violence against persons or property in violation of the criminal laws of the United States for purposes of intimidation, coercion, or ransom. Terrorists often use threats to create fear among the public, to try to convince citizens that their government is powerless to prevent terrorism, and to get immediate publicity for their cause” (FEMA, 2007).

In the Code of Federal Regulations (CFR), terrorism is defined as “the unlawful use of force and violence against persons or property to intimidate or coerce a government, the civilian population, or any segment thereof, in furtherance of political or social objectives” (FBI, n.d.).

Unlike strictly criminal acts, which pose a threat of personal injury of some sort, terrorism generally reflects “motivations that are chiefly political, ideological, or religious; often, some element of symbolism in the choice of target, together with the desire to elicit fear in a larger audience beyond the immediate victims of an attack” (FEMA, 2007).

How does a mass casualty incident (MCI) fit into this concept? An MCI is a situation “which generates more patients than available resources can manage using routine procedures” (Green, 2006). Terrorists usually select targets that will produce large numbers of casualties, so it is safe to assume that most acts of terrorism will also be MCIs. This means that healthcare providers and facilities will have to change the way they normally practice to appropriately respond to an act of terrorism.

Types of Terrorist Attacks

In seeking to understand terrorism, you may also encounter three additional “either/or” pairs of definitions:

  • Domestic vs. international terrorism
  • Hard vs. soft targets
  • Overt vs. covert attacks

Referring to terrorism as “domestic” and “international” differentiates between the origin of the individuals or groups responsible for it, not to where the terrorist act takes place. The bombing of the Murrah Federal Building in Oklahoma City was an act of domestic terrorism, because those responsible were U.S. citizens. The events of September 11 were international terrorism, because although the targets were in the United States, the perpetrators were foreign nationals.

The relative hardness of a target refers to the amount of protection (physical structure, security personnel, and/or access controls) it has. A hard target is one that heavily protected and would be difficult to penetrate by either brute force or infiltration. For example, in the aftermath of the September 11 attacks, commercial airliners have been significantly hardened. A soft target is one with relatively few or no layers of protection. By their very mission, healthcare facilities need to be readily accessible to both patients and caregivers. It is sobering to realize that healthcare facilities’ necessary openness makes them very “soft” indeed.

An act of terrorism may be either covert or overt, depending on whether the group announces its intent in advance. A covert attack takes its advantage from the element of surprise. Because of this, victims may arrive in multiple healthcare facilities before those facilities are aware there has been an attack and can implement their response plans. Besides creating an obvious overload, such victims may contaminate the facility or caregivers, thus limiting the ability of the system to care for them or later-arriving victims.

An overt attack, because it is predicted in advance or immediately claimed by the responsible group, relies heavily on panic as an impact multiplier. The announcement prompts individuals in both the identified target area and well beyond to seek information and assistance from public and private resources. The sheer number of victims to be triaged may precipitate an MCI that overwhelms even systems that have a robust emergency response plan in effect.

In either scenario, because many terrorists’ choices of agents have subtle and subjective symptoms, the system with may be flooded with both actual victims and people who are not affected but believe they have been.

Weapons of Mass Destruction

In the popular press, the term weapons of mass destruction and its acronym, WMD, have taken on polarizing political overtones. However, those terms must retain an objective implication for healthcare providers if they are to respond appropriately if such weapons are used. That is, stick to the facts, whether your politics are red, blue, or absent.

According to the Department of Defense (2007), WMDs are “weapons that are capable of a high order of destruction and/or of being used in such a manner as to destroy large numbers of people. Weapons of mass destruction can be high explosives or nuclear, biological, chemical, or radiological weapons, but exclude the means of transporting or propelling the weapon where such means is a separable and divisible part of the weapon.”

There are several taxonomies for differentiating between the types of weapons of mass destruction. The “B-NICE” acronym, from the Community Emergency Response Team (CERT) manuals, is an ironic but effective memory aid (CERT, 2003).

  • Biological weapons
  • Nuclear weapons and radiological dispersive devices
  • Incendiary devices
  • Chemical weapons
  • Explosive weapons

This course will focus on specific implications of the triad of nuclear/radiological, biological, and chemical—or “NBC” weapons. This course will not cover caring for victims of incendiary and/or explosive weapons, since the general principles of trauma care for patients suffering from burn or blast injuries apply to victims of terrorism using incendiary or explosive weapons.

If a “combined” weapon is known or suspected to have been used, caregivers should consider the need for PPE and the requirement to decontaminate the victim prior to or concurrent with treatment.


The use of radiation as a terrorist weapon may be either over or covert.

An overt attack could be carried out by the intentional deployment of a nuclear weapon or the use of a radiological dispersive device (RDD) or “dirty bomb.” The latter involves the dispersal of nuclear material by using conventional explosives.

Both nuclear weapons and RDDs used in an overt attack have several things in common. They have the ability both to create damage (due to the explosive power of the weapon) and to contaminate persons and inanimate objects (due to the inclusion of radioactive material). Both rely heavily on the public fear of anything associated with nuclear use or radiation. Caring for their victims triggers the consumption of vast amounts of personnel and material resources to decontaminate casualties and clean up contaminated debris.

They differ in how the nuclear material is used. The creation of a true nuclear weapon requires the logistical and financial support to acquire the materials and the skill to create and deliver it. These complex factors may put it beyond the range of all but the most well-organized, supported, and financed groups.

An RDD also requires access to nuclear material but can use more readily available commercial-grade material. It also relies on far less sophisticated conventional explosive technology to disperse it. This makes it a potential weapon for a wider range of terrorists groups.

Placing radioactive material in a location where it would expose unsuspecting victims or contaminate common-use objects is how a terrorist group might conduct a covert attack. Examples include concealing it in a high-traffic location or contaminating food or water sources. A covert attack is a “low-tech” way to conduct radiation terrorism. Logistical requirements might be as simple as a trowel to bury material in planters at a busy public transportation plaza or a take-out cup to carry the contaminant around a crowded market.

Radiation Basics

In its purest meaning, radiation is any form of energy propagated as rays, waves, or energetic particles that travel or radiate from their source. Radioactive materials are composed of atoms that are unstable. An unstable atom gives off its excess energy until it becomes stable. The energy emitted is radiation. The process by which an atom changes from an unstable state to a more stable state by emitting radiation is called radioactive decay or radioactivity (CISAC, 2002a,b).

Radiation can be either non-ionizing or ionizing. Non-ionizing radiation has enough energy to move atoms in a molecule or cause them to vibrate, but not enough to change them chemically. Examples include radio waves and visible light. Ionizing radiation has enough energy to break the bonds that tie electrons into the atoms or molecules that make up ordinary substances. It deposits a large amount of energy into a small space. This can be a positive attribute when it is used as a method of medical treatment or negative when it is harnessed into a weapon.


How radiation is expressed is determined by the relationship of its amount to another factor. There are two systems in use; the conventional system is generally used in the United States.

What is Being Measured Conventional System Système International d’Unités (SI) Conversion Factor
Sources: CDC, 2003a; Wolbarst et al., 2010.
Radiation given off by a radioactive material Curie (Ci) Becquerel (Bq) 1 Ci = 3.731010 Bq
Radiation dose absorbed by a person Rad Gray (Gy) 100 Rads = 1 Gy
Biologic risk of exposure to radiation Rem Sievert (Sv) 100 Rems = 1 Sv

It is critical to note that exposure to radiation does not make a person radioactive. A patient undergoing diagnostic or external therapeutic radiation is exposed but not radioactive. Victims of a radiation terrorist attack are in the same category as patients undergoing invasive radiation therapy. Once the radioactive material is removed from their bodies by decontamination, they do not pose a risk to care providers.


Because radiation cannot be detected by human senses, a device must be used to confirm or exclude its presence. In the case of a radiation terrorism incident, two general types of devices will be used, one to survey victims or healthcare workers and the other to monitor healthcare workers’ cumulative exposure


Radiation survey meter. (Source: Radiation Emergency Assistance Center/Training Site.)

Radiation survey meters, colloquially known as “Geiger counters,” identify the presence of radiation in the environment or on the surface or within victims. They are used during triage and decontamination of victims.

The second type of measuring device is a personal dosimeter, and it is part of the PPE for persons facing exposure to radiation as part of their duties. “Personal” dosimeters are just that: they are intended to monitor the exposure of one individual. They should not be shared, as that would provide incorrect information on any and all persons involved in the sharing.

The dosimeter used during a radiation emergency such as the aftermath of a terrorist attack will most likely differ from that used during routine healthcare provision. The everyday film badge, as it is often called, or similar ring devices are not self-reading and do not provide real-time information on exposure.

Given the relatively low levels of radiation exposure experienced in usual circumstances, the monthly or quarterly reporting interval of film-badge-type monitoring provides adequate exposure information to both the wearer and those responsible for facility radiation safety. However, in the event of a terrorist attack using radiation, care providers will have much greater than usual potential exposure over a significantly shorter period of time. They will need real-time information on their exposure so they can remove themselves to a safe area before they exceed recommended levels.

Information on exposure must be immediately available to the wearer when (s)he is responding to a radiation emergency. The normal safeguards of time-distance-shielding are reduced or absent, given the urgent need of the victims. The newest personal dosimeters provide sophisticated real-time information on exposure; many come with alarms to indicate that the wearer is approaching maximum allowable exposure and have the ability to automatically download information to a computer.


Dosimeters: film badge (left), ring badge (center), and real-time (right). (Source: OSHA and U.S.D.H.S.)


Radiation injury to the body happens in one or more ways. External irradiation occurs when all or part of the body is exposed to penetrating radiation from an external source. This radiation can be absorbed by the body or it can pass through the body.

Radioactive contamination occurs when radioactive material is deposited on or in an object or a person. Radioactive materials released into the environment can cause air, water, surfaces, soil, plants, buildings, people, or animals to become contaminated. A person exposed to radiation is not necessarily contaminated. For a person to be contaminated, radioactive material must be on or inside the body.

Radioactive contamination can be external, internal, or both. When radioactive materials—in the form of dust, powder, or liquid—come into contact with a person’s skin, hair, or clothing, he or she is considered externally contaminated. External contamination can be removed by shedding contaminated clothing and/or completely washing off the source of radioactivity.

If radioactive materials get inside the body through the lungs, gut, skin, or wounds, the contaminant can become deposited internally. Incorporation is the process of the uptake of radioactive materials by body cells, tissues, and target organs such as bone, liver, thyroid, or kidney. Incorporation cannot occur unless contamination has occurred (ORISE, 2002). Internal contamination continues until the radioactive material decays, is flushed from the body by natural processes, or is removed by medical countermeasures.


Once a person has been exposed to radiation beyond a therapeutic dose, radiation-induced illness may occur. Two major categories have been identified: acute radiation syndrome (ARS) and cutaneous radiation syndrome (CRS) (CDC, 2005a, b).

Acute Radiation Syndrome

ARS is caused by total or near-total body irradiation by a high dose (>0.7 Gy or >70 rads) of external, penetrating radiation over a very short period of time (minutes). Onset and severity of symptoms are related to the severity of exposure. Victims in close proximity to the detonation of either a nuclear device or an RDD would receive the intense exposure that causes ARS.

There are three stages of ARS:

  1. In the prodromal stage, the patient experiences nausea, vomiting, anorexia, and possibly diarrhea. This can occur episodically within minutes to days following exposure; the duration of symptoms can vary.
  2. Following the prodromal stage, the patient looks and feels generally healthy for a few hours to a few weeks. This is the latent stage.
  3. The patient begins to experience symptoms specific to the part(s) of the body affected during the manifest illness stage. The symptoms depend on the specific syndrome (bone marrow or hematopoietic, gastrointestinal, or cardiovascular) and last from hours to several months.

The recovery process lasts from several weeks to two years. Most patients who do not recover will die within several months of exposure (CDC, 2005b).

Cutaneous Radiation Syndrome

As the name implies, CRS presents as skin damage manifesting within hours, days, or weeks after exposure. It usually accompanies ARS and is caused by acute exposures to beta radiation or x-rays or contamination of the patient’s skin or clothes. The patient experiences transient itching, tingling, erythema, or edema within hours or days. This is usually followed by a latent period. Lesions may not be seen for weeks to months post-exposure but then can be debilitating or even life threatening.

Syndromic Surveillance

Syndromic surveillance is the collection of data about a series of incidents to determine if they represent isolated occupancies with only the appearance of a common cause, or if they are true indicators of a pattern. The starting point is a member of the healthcare team noting something out of the ordinary and asking, “What is going on?” It relies as much on objective knowledge of community trends as the instinct most people develop about what is “normal” for their setting.

If even one person presents with symptoms suggestive of nontherapeutic radiation exposure, aggressive investigation to discover the circumstances is warranted. Determination of the cause (accidental exposure, such as a workplace incident or intentional exposure caused by terrorists) will determine what actions beyond caring for the victim(s) are indicated.

Once the index of suspicion is raised, data is needed to rule in or out commonalities. The questions for syndromic surveillance in the case of possible radiation terrorism home in on the victim’s circumstances more than symptoms:

  • Where were you before you started experiencing…?
  • What were you doing/eating/touching…?
  • When did this happen?
  • Were you alone or in a group?

The questioner needs to pose these questions in a sensitive manner. As soon as the possibility of a terrorist act or radiation incident is even implied, the victim’s focus will likely shift inward. All but the most altruistic individuals will initially be more concerned with their own well being and that of their immediate circle than “the greater good.” The questioner should help the patient remain calm and focused by providing fact-based reassurance while eliciting information that might provide clues to the scope of the incident.

In the case of a known or suspected covert radiation terrorist attack, syndromic surveillance focuses on case-finding and data collection. A covert release may lead to staggered (over time and to multiple facilities) patient presentation. The prompt collection and interpretation of data in a coordinated manner can decrease the time it takes authorities to locate and neutralize the radiation source(s). This will end the production of new victims. A secondary gain is the reinforcement of public confidence in the ability of the system to protect its people.

The primary function of syndromic surveillance in the case of an overt attack is as much triaging data as it is collecting it. Sorting out those most likely to have been affected from those frightened about the possibility will give a truer picture of the event as a whole.

Treating Victims of Nuclear/Radiation Terrorism

The underlying, overriding principle in treating victims of radiation terrorism is simple: addressing contamination issues should not delay treatment of life-threatening injuries. Some victims of a terrorist attack involving radiation, especially if an RDD was used, will have immediate, life-threatening injuries. Thus, the initial care team should include staff with expertise in radiation safety as well as trauma-related injuries.

The facility disaster plan should contain information on how to contact individuals with this type of experience. For facility staff, an up-to-date alert roster should be readily available. If this expertise is not available in-house, a consultative relationship with a larger institution may be the answer, and that should be included in the disaster plan. In the absence of either of these options, or to augment them, the Radiation Emergency Assistance Center is available 24/7/365 (see “Resources” at the end of the course). This agency’s function includes deploying to and providing emergency medical consultation for incidents involving radiation anywhere in the world.


Two functions will occur in the triage area. Actual or potential victims will be distinguished from those people seeking information or reassurance, who will be routed to an appropriate area to receive those services. Secondly, those requiring decontamination and treatment will begin that process. This may include any healthcare providers who were exposed prior to learning of the radiation risk among patients.

The triage area should consist of contaminated and clean zones separated by a buffer zone. It should be located in an area where environmental and geographic factors will not lead to contamination of the facility as a whole. The decontamination area may be a permanent, purpose-built decontamination chamber or area, or it may be a temporary structure assembled as needed from prepositioned supplies. In simple terms, think of keeping contamination “downhill and downwind” from the facility. Consult the facility disaster plan for information on location and detailed setup.

Personal Protective Equipment (PPE)

If assigned to work in the triage area, don appropriate PPE and use standard protection precautions. These are based on the theory of infection control Universal Precautions. The cornerstone of personal protection is the correct, consistent use of PPE.

In this case, PPE includes surgical attire (scrubs, impervious coverall suit or gown if coverall not available, mask, head cover, waterproof shoe covers, eye protection, and double gloves). N95 masks, if available, are recommended. The first pair of gloves is worn under the gown cuff and secured with tape; the second pair is worn over the cuff for ease of changing as needed.

Secure any open cuffs, hems, etc., with tape. Use a fold-over tab to facilitate the removal of tape. Wear a personally assigned dosimeter on the outside of the gown. A second dosimeter may be worn under the gown if facility policy dictates. If wearing a surgical gown, wear a waterproof apron over the gown when using liquids for decontaminating victims (USDHHS, 2010).

Lead aprons are not necessary. Their use can give a false sense of security and lead to disregard of evidence-based actions (ORISE, 2000/2002).

The use of science-based policies and procedures will protect caregivers. It is highly unlikely that the levels of radioactivity associated with a contaminated patient would pose a significant health risk to care providers if they follow protocols. However, due to fetal sensitivity to radiation, pregnant staff should be assigned to duties that will not put them in contact with exposed patients or contaminated materials (CDC, 2005a).


OSHA has made a clear distinction between the site where a hazardous substance was released and hospital-based decontamination facilities. This distinction is important because it helps define the maximum amount of contaminant to which healthcare workers might be exposed (i.e., the quantity of material on living victims and their possessions when they arrive at the hospital).

The OSHA “best practices” document notes that during victim decontamination procedures, the hazard to healthcare workers is strictly from secondary exposure and is dependent on the type and strength of the contaminant and how long the worker is exposed to it. Thus, the possible exposure of first receivers is limited to the amount of substance arriving at the hospital as a contaminant on victims and their clothing or personal effects.

In the event of a primary or secondary attack at or near a healthcare facility, first receivers at that facility would face the increased level of exposure usually experienced by first responders. They would need to use the same PPE as first responders (OSHA, 2005).

Initial Survey

Decontamination is a systematic process of evaluation, action, and reevaluation where objective findings determine the next step. It begins with an initial survey of the victim with a radiation meter. It should be done only by trained personnel using consistent technique to obtain valid, comparable results. The surveyor observes for both surface and embedded material. On-site radiation professionals are included on the response team to perform or supervise this function. Handle any visible radioactive material with forceps and store in lead or lead-lined containers. Document the details of survey, including date, time, surveyor, meter used, and findings (CDC, 2005a).


In the event of suspected radiation contamination, healthcare personnel will use an instrument such as a GM meter (or Geiger-Mueller radiation instrument) to survey a patient.

  • Perform survey instrument check
    • Check instrument for calibration certificate
    • Perform battery charge check
    • Select desired survey mode
    • Obtain and record background reading
  • Position person to be scanned
    • Standing upright on a clean pad
    • Feet spread slightly
    • Arms extended from body, palms up, fingers extended from the hand
  • Conduct survey
    • Hold the probe about 1/2 inch from the surface being surveyed
    • Scan surfaces at a rate of 1–2 inches per second
    • Pass the probe over the body in a systematic way over the front, back, sides, head, armpits, groin, soles of feet, etc.
    • Hold the probe over areas of elevated readings for about 10 seconds to determine the “count rate”
    • Scan one side of the body at a time; repeat systematically on the reverse side
    • Record survey results or “count rates” on a body chart diagram before and after each decontamination cycle

Source: Radiation Emergency Assistance Center/Training Site.

Source: DHHS, 2011.

Removing Clothing

Once the initial survey is complete, remove the victim’s clothing. Cut and roll the clothing so that the outer surfaces are confined and contained within the rolls and any radioactive debris is also incorporated. Roll away from the face and any open wounds. Roll gently to avoid dispersing any radioactive debris.

Double-bag and label the clothing; preserve and store as possible evidence, following instructions in the facility disaster plan.

Secondary Survey and Cleaning

Once the victim’s clothing has been removed, perform a secondary survey in the same manner as discussed above. Then proceed to decontaminate the victim.

Allow the victim to assist or participate to the extent possible. Even the small measure of autonomy this provides may allow the victim to feel a degree of control over what has happened. Rinse any wounds with tepid saline or water.

If facial contamination is known or suspected, flush the eyes, ears, and nose and rinse the mouth. Clean intact skin gently with soap and water, starting outside the contaminated area and working inward. Do not scrub or rub the skin. Dry the skin gently and cover the victim’s exposed skin once an area has been decontaminated. This serves the dual purpose of preventing unnecessary exposure and preventing loss of body heat.

For mass casualties, consider establishing separate shower areas for ambulatory and nonambulatory patients.

Perform a tertiary survey as discussed above and repeat decontamination steps, alternating with surveys, until radiation level is no more than twice background or unchanged from the immediate previous reading.

Cover any wounds with waterproof dressings and transport or assist the victim to the buffer zone. At that point, someone assigned to the buffer zone will assume responsibility for the victim. Once the victim has been decontaminated, Universal Precautions and routine assessment and care pathways are indicated (CDC, 2005a).

Dispose of wastewater and decontamination materials as directed by the facility policies.

When leaving the contaminated area, assigned personnel should remove and properly dispose of contaminated outer garments, shower if indicated in the facility disaster plan, and receive a body survey with a radiation meter.

Assessing for Internal Contamination

Consider internal contamination if high survey readings persist following decontamination. Internal contamination generally does not cause early symptoms. Nose or mouth contamination may indicate inhalation or ingestion. Assessment may include analysis of urine, blood, and fecal samples or whole-body counts. Consult with radiation experts regarding an individualized treatment plan. For internal contamination, the following may be options: early administration of radionuclide-specific decorporation agents such as Prussian blue, DTPA, or bicarbonate and/or gastric lavage, and/or antacids and/or cathartics to assist in clearing ingested contaminants (CDC, 2005a).


Following the explosion of a dirty bomb at a crowded nearby train station, contaminated bystanders are transported to the local hospital emergency room. ED staff have been notified in advance and are wearing appropriate PPE when the victims begin to arrive. Treatment is begun immediately for unstable patients. For those without life-threatening injuries, providers begin by removing contaminated clothing from the individuals and placing it in property bags that are then properly labeled. Using GM meters that they have already checked, they conduct whole-body scans of the patients and record the readings.

Some victims have been injured by shrapnel from the blast. ED staff remove the shrapnel to protect against possible internal contamination. They clean the wounds, carefully catching any water run-off. They also wash the patients’ bodies with soap and water to remove any external contamination. They then complete a second scan to determine the degree to which the decontamination process was successful.


Treat vomiting immediately. Perform serial CBCs (emphasizing lymphocyte count) every 2 to 3 hours for the first 8 to 12 hours after exposure (and every 4 to 6 hours for the following 2 to 3 days). Precisely record all clinical symptoms, particularly nausea, vomiting, diarrhea, and itching, reddening, or blistering of the skin, including time of onset. Note and record areas of erythema. If possible, take color photographs of suspected radiation skin damage. Consider tissue and blood typing, as well as initiating viral prophylaxis.

Promptly consult with experts in radiation, hematology, and radiotherapy and radiation accident management about dosimetry, prognosis, and treatment options. After consultation, begin the following treatment (as indicated): supportive care in a clean environment (burn unit or similar area); prevention and treatment of infections; stimulation of hematopoiesis by use of growth factors, system cell transfusions, or platelet transfusions (if platelet count too low); psychological support; observation of existing or new onset erythema hair loss, skin injury, mucositis, parotitis, weight loss, or fever (CDC, 2005b).

With CRS, delayed occurrence of lesions is a differentiating factor from thermal burns. An important part of treatment is to document time of occurrence of lesions and progressive changes in appearance. Treatment of localized injuries is symptomatic, focusing on pain relief and prevention of infection (CDC, 2005a).


A victim who died after being exposed to a lethal dose of radiation without contamination is not radioactive and no special precautions are needed.

If the deceased victim is known or suspected to be contaminated either internally or externally, the body should be surveyed to determine the degree of contamination. The same procedure is used as for an initial survey of a living victim, using the same PPE.

Bodies should be tagged with both identification and radiation warning tags.

Autopsy of minimally radioactively contaminated cadavers does not require precautions other than contamination control and protective clothing. Autopsies of highly radioactive cadavers should be restricted to the absolute minimum. For both exposure control and minimizing the impact on those performing these autopsies, it may be advisable to split the task among several persons.

Issues related to both burial and cremation are a function of the amount and type of radioactive material that remains in the body (DHS, 2003).

Psychosocial Aspects of Radiation Terrorism

Terrorists count on the general public’s fear of anything to do with radiation as a force multiplier. The number of patients seeking care is directly related to population size. In urban areas, this could be hundreds to thousands. Most will self-refer to the nearest hospital. While many may need decontamination, others may seek radiologic screening even though not contaminated. Many simply seek reassurance. Psychogenic symptoms, such as nausea or vomiting, may manifest. Mental health professionals should always be members of the response team and available in any first-receiver facility to provide such support.

Have radiation exposure fact sheets available for patients and families. As with all care, information must be in-language to meet a number of regulatory and voluntary accreditation standards and, more importantly, the needs of patients and their loved ones. Have translated sheets available in the predominant languages spoken in the area and/or use interpreters.

When interpreters are required to obtain or convey information, use previously identified facility staff whenever possible. Over-the-phone providers of interpretation are available, both as a subscription service and on an as-needed basis. Use family members or significant others only as a last resort. Most likely, they will be too overwhelmed by the situation to be effective communicators.

Pregnant patients and their families/significant others will require special counseling. Also consider establishing separate areas for radiation screening and counseling for patients with minimal risk of exposure or injury (CDC, 2005a).

Reporting Procedure

Call the Radiation Emergency Assistance Center (see “Resources” at the end of this course) to record the incident in the Radiation Accident Registry System. Consult the facility disaster plan to determine who has the authority and responsibility to perform this notification.


Biological weapons or biological warfare agents are “microorganisms such as viruses and bacteria that infect humans, livestock, or crops and cause an incapacitating or fatal disease. Symptoms of illness do not appear immediately but only after a delay, or ‘incubation period,’ that may last for days to weeks” (CNS, 2008).

The organisms themselves are found in nature but have been “weaponized,” or adapted for use as a weapon. They will affect a broader segment of the human or animal population or crops than the naturally occurring form of the pathogen.

While the “chain of infection” still applies to diseases caused by exposure to biological weapons, the obvious difference is the mode of transmission link. Naturally occurring disease is almost always spread unintentionally. In many cases, it occurs as part of carrying out normal daily activities, with a contaminated hand or uncovered sneeze passing on the infectious agent. Intentional spread indicates biological terrorism.

Preparation to deal with bioterrorism has much in common with the epidemiology of emerging infectious diseases. As they do with naturally occurring diseases, healthcare providers and public health agencies must be prepared to deal with pathogens not normally presenting in this country or varying in their presentation and/or severity.

Terrorist groups may conduct either covert or overt releases of biological warfare agents. In the case of an overt attack, healthcare facilities in the immediate area will be inundated with victims, possibly without regard to the relationship between the stated time and place of release and the known incubation period.

If the attack was covert, the arrival of victims at one or more perhaps widely spread facilities may be the first indication that an act of terrorism has occurred. Because most pathogens have an incubation period before the infected person begins to show symptoms, the attack may remain silent for some time. Additionally, infected individuals may further spread the agent just by following their daily routine.

Biological agents may be dispersed by several means. Only aerosol sprays are reasonably practical. The use of small fixed-wing or rotary aircraft are an effective way to accomplish this. Explosive blasts have the potential to inactivate the agent. Contaminating public water supplies is not practical; it requires a large amount of agent to be introduced into the water after it passes through the water treatment facility.

Syndromic Surveillance for Bioterrorism

Healthcare providers—including emergency department and acute care clinic physicians, nurses, and assistive personnel and infection prevention specialists—play a key role in initiating the response to an act of bioterrorism. Their knowledge of what is usual among their patient population will provide the starting point for syndromic surveillance.

Syndromic surveillance specific to bioterrorism refers to active surveillance of syndromes. These are case definitions based entirely on clinical features without any clinical or laboratory diagnosis that may be caused by potential agents used by biologic terrorists and sometimes refers to alternative measures such as increases in the use of over-the-counter drugs or increases in calls to emergency departments (Jamison et al., 2006).

The most common features of an outbreak caused by bioterrorist agents include:

  • A rapid increase (hours to days) in the number of previously healthy persons with similar symptoms seeking medical treatment
  • A cluster of previously healthy persons with similar symptoms who live, work, or recreate in a common geographical area
  • An unusual clinical presentation
  • An increase in reports of dead animals
  • A lower incident rate in individuals who are protected (e.g., confined to home with no exposure to large crowds)
  • An increase in number of patients who expire within 72 hours after admission to the hospital

Note that these factors all reflect changes from the norm; here is where the astute observer with a finger on the community’s general “ health pulse” can make a significant difference in how soon a response to the threat begins.

All of the previous clinical features deal with pattern changes in the community, not the victim’s whereabouts prior to becoming ill. The one exception to the community comparison is any person with a history of recent (past 2–4 weeks) travel to a foreign country who presents with symptoms of high fever, rigors, delirium, rash not characteristic of measles or chickenpox, extreme myalgias, prostration, shock, diffuse hemorrhagic lesions or petechiae, and/or extreme dehydration due to vomiting or diarrhea with or without blood loss.

This aids in distinguishing between a potential victim of a biological weapon and a person who has been exposed to a naturally transmitted disease to which they have no community-acquired or vaccination-provided immunity.

While equipment for detecting and identifying biological agents does exist, there are significant drawbacks to the systems currently available. As it currently exists, the technology is geared toward detecting agents in the environment so that first responders can take appropriate precautions. It is not intended to be an aid to diagnosis. The equipment is complex and requires extensive initial and refresher training to insure the delivery of accurate information. Those factors, in addition to the cost involved to purchase and maintain such a system, keep this from being a practical community option.

Diseases with Potential for Use as Bioweapons

The CDC has classified into three categories more than thirty organisms as having potential for use as a biological weapon. Classification is based on ease of dissemination, morbidity and mortality (M&M), potential for panic and social disruption, and requirements for public health preparedness.

  • Category A diseases or agents are the highest priority, including those that pose a risk to national security. Included are anthrax, botulism, plague, and smallpox.
  • Category B diseases are less easy to disseminate and result in lower M&M.
  • Category C diseases are emerging pathogens that could be engineered for mass dispersion and have the potential to cause high M&M.
    (CDC, 2007a)

Bacillus anthracis is a spore-forming organism, with the spores being the infectious element. In its natural state it is present in the soil, where it may be ingested by grazing animals. It can be transmitted to humans by handling or ingesting contaminated animals, animal products, or soil. Unless exposure is due to an intentional release, anthrax infections are very rare.

If contamination is from aerosolized powder or environmental exposures, PPE includes a respirator such as an N95 mask or equivalent or a powered air-purifying respirator (PAPR). Protective clothing is needed for decontamination of persons with powder on them.

Source: CDC, 2007c.
  • First stage (10 days–6 weeks after exposure): nonspecific flu-like symptoms, fever, dyspnea, cough, congestion, anterior chest discomfort
  • Second stage (2–4 days after initial symptoms): respiratory failure, sepsis, hemodynamic failure
Treatment 60 days of appropriate antibiotic, plus supportive intensive care
PPE Standard Precautions
  • Hand hygiene must be a vigorous wash for 30–60 seconds with soap and water or 2% chlorhexidene gluconate after spore contact (alcohol handrubs inactive against spores)
  • Not contagious person-to-person
Source: CDC, 2007c.
  • Within 2 weeks of exposure
  • Local edema in area of contact, progressing to itching macule or papule, then ulceration, then eschar formation
  • May include lymphangitis and lymphadenopathy
Treatment 60 days of appropriate antibiotic and wound care
  • Standard Precautions
  • Add contact precautions if uncontained copious drainage is present
  • Hand hygiene: Handwashing for 30–60 seconds with soap and water or 2% chlorhexidene gluconate after spore contact (alcohol handrubs inactive against spores)
  • Most commonly occurring form; about 2,000 cases annually worldwide
  • Fatality: 1% if treated; ≥20% if untreated
Source: CDC, 2007c.
  • 2–5 days of ingesting of ingesting contaminated meat
  • Fever, diffuse abdominal pain and tenderness, nausea, and vomiting
  • May cause ulcerative lesions progressing to bowel perforation
Treatment 60 days of appropriate antibiotic, plus supportive care
PPE Standard precautions
  • Hand hygiene must be a vigorous wash for 30–60 seconds with soap and water or 2% chlorhexidene gluconate after spore contact (alcohol handrubs are inactive against spores)
  • Not reported in the United States

Several workers at a nearby bank were servicing the ATMs. One of the envelopes contained currency and a note stating the bills had been contaminated with anthrax. The workers were brought to the nearby hospital, and the facility disaster plan was activated.

The initial exposure at the bank was noted immediately and the area secured. The note stated that the attack was directed specifically at that branch. Given these circumstances and syndromic surveillance, authorities felt that no widespread exposure occurred.

As part of the disaster plan, the information officer conducted press conferences, stressing the reasons why there was no need for concern on the part of anyone not already identified as having been exposed. The community emergency operations center (EOC) notified all healthcare facilities in its catchment area. The social media liaison ensured that accurate information was immediately posted to the facility’s public and in-house websites and social media accounts. All departments were briefed, and the alert system was used to inform off-duty personnel of the extent of the incident.

To no one’s surprise, worried citizens showed up in large numbers. The infection preventionists, assisted by employee health and security personnel, set up a series of checkpoints to direct the “walking worried” to areas where they could express their concerns and be educated and reassured. Checkpoint personnel also sorted out friends and families of the exposed so they could receive support and information before they were reunited with the victims.


Clostridium botulinum is also a soil-inhabiting, spore-forming organism. The neurotoxin it forms is extremely potent; <1 microgram is fatal for adults. It causes respiratory paralysis. Without treatment, death can occur. Thirty to fifty cases of food-borne botulism occur in the United States annually. Botulism can be contracted by ingesting contaminated canned, smoked, or vacuum-packed foods, but also by inhaling spores.

Source: CDC, 2006b.
  • Adults: drooping eyelids, weakened jaw clench; difficulty swallowing, speaking, and seeing; symmetrical descending proximal-to-distal weakness and respiratory dysfunction
  • Infants and children: loss of head control, limb weakness, respiratory distress, constipation, lethargy, and loss of gag reflex
  • Antitoxin (available from CDC; may reduce severity of symptoms)
  • Supportive care, including mechanical ventilation if needed
PPE Standard Precautions
Notes Can be prevented by administration of neutralizing antibody in the bloodstream; passive immunity can be provided by equine botulinum antitoxin or by specific human hyperimmune globulin, while endogenous immunity can be induced by immunization with botulinum toxoid
Source: CDC, 2006b.
Presentation As for food-borne, but lacking GI symptoms
  • Antitoxin (available from CDC; may reduce severity of symptoms)
  • Supportive care, including mechanical ventilation if needed
PPE Standard Precautions

Yersinia pestis is a bacterium that causes acute, potentially fatal infections in both humans and animals. It is naturally occurring in the United States, with 10–15 cases per year, mostly in Arizona, Colorado, and New Mexico. Plague is rarely naturally transmitted by inhalation, but that is the most likely means if the organism were to be released intentionally. If released as an aerosol, an outbreak of pneumonic plague is the anticipated result.

There are five principle forms of plague in humans, with bubonic, pneumonic, and septicemic being the most common. Plague meningitis and pharyngeal plague are the others. Ocular plague has been reported in free-ranging mule deer.

Source: USNLM, 2011.
  • 2–6 days after exposure: buboes (grossly enlarged, extremely tender lymph nodes with drainage at the inoculation site) and fever
  • If untreated, can progress to septicemia or secondary pneumonic plague or plague meningitis
  • Antibiotics (streptomycin, doxycycline, gentamycin, ciproflaxin)
  • Supportive measures: oxygen, IV fluids
PPE Standard Precautions
Notes Without treatment, about 50% fatality
Source: USNLM, 2011.
  • 1–6 days: acute onset of fever & chills, malaise, myalgias, and progressive lethargy
  • If untreated, can progress to adult/acute respiratory disease syndrome and refractive pulmonary edema, shock, hypotension, and multiple organ system failure or plague meningitis
  • Antibiotics (streptomycin, doxycycline, gentamycin, ciproflaxin)
  • Supportive measures: oxygen, IV fluids
PPE Droplet precautions until patients have received 48 hours of appropriate antibiotics, then Standard Precautions
Notes Without treatment, about 50% fatality
Source: USNLM, 2011.
  • Usually secondary to pneumonic or bubonic plague; may be primary presentation
  • Acute onset of fever and chills, prostration, abdominal pain, nausea, and vomiting
  • May progress to include purpura, disseminated intravascular coagulopathy, hypotension, and shock
  • Antibiotics (streptomycin, doxycycline, gentamycin, ciproflaxin)
  • Supportive measures: oxygen, IV fluids
PPE Standard Precautions

The variola virus causes smallpox in two forms. Variola major is the most common and most severe. It has a historical fatality rate of ~30%. Variola minor is less common and severe, with a historical fatality rate of ≤1%.

Transmission begins with virus particles being sloughed from the oropharyngeal lesions of an infected person. Inhalation of airborne droplets of this saliva introduces the disease to a new host. It can also be spread by direct contact with droplets or contaminated items such as clothing, bedding, or tissues.

Currently, the United States has a big enough stockpile of smallpox vaccine to vaccinate everyone in the United States in the event of a smallpox outbreak (CDC, 2007b).

Source: Mayo Clinic, 2011.
  • 2–4 day nonspecific prodrome (fever, myalgia)
  • Vesicular/pustular rash developing simultaneously on the face and extremities
  • No specific treatment
  • Isolation
  • Supportive treatment, including fluid replacement and antibiotics for secondary skin infections
  • Vaccination before or within 2–3 days after exposure affords almost complete protection against developing disease
  • Vaccination as late as 4–5 days after exposure may protect against death but not disease development
PPE Combined use of Standard, airborne, and droplet precautions until all scabs have separated (usually 3–4 weeks)
Notes All emergency medical services and hospital personnel exposed to someone with smallpox require quarantine and vaccination if they have not been previously vaccinated

Personal Protective Equipment

The chain of infection applies to both naturally occurring diseases and those caused by bioweapons.

The general principles of PPE for bioterrorism are based on the same precautions as those used to protect otherwise healthy patients from acquiring a healthcare-associated infection and in caring for patients with known or suspected benignly transmitted infections. These actions are often referred to as “Standard” or “Universal” precautions because they are in use with all patients. They include hand hygiene and, depending on the anticipated exposure, the use of gloves, gowns, masks, eye protection, or face shield.

With Universal or Standard transmission-based precautions, the portal of exit and mode of transmission determine the equipment needed. They are based on the principle that all blood, body fluids, secretions and excretions (except sweat), nonintact skin, and mucous membranes may contain transmissible infectious agents.

Specific PPE measures are discussed in conjunction with the disease presentations to which they apply. Consult the facility infection control manual for details on policies and products in use.


The first use of chemical weapons in declared warfare began in World War I, and they were most likely used again by the Iraqi army against the Kurds in late 1980s. Chemical agents are attractive to terrorists because they or their precursors are readily available. A glance at most kitchen sinks or garages will reveal any number of potential chemical weapons. As discussed in the earlier section on biological agents, releases may be overt or covert, with the same associated triage and psychosocial issues.

Symptoms of exposure to some chemical agents might be similar to those of common diseases. Immediate symptoms of certain chemical exposures might be nonexistent or mild despite the risk for long-term effects. Exposure to contaminated food, water, or consumer products might result in reports of illness over a long period and in various locations. Persons exposed to two or more agents might have a mixed clinical presentation. Healthcare providers might be less familiar with chemical agent presentation than with familiar illnesses (CDC, 2003b).

Chemical agents may be delivered by a variety of methods, limited only by the technology available to the terrorists. They may be dispersed by spraying of aerosolized agent or exploding a dispersal device. An agent may also be used to contaminate food, water, or some other necessity or commonly used item or by compromising a chemical manufacturing, storage, or distribution facility.

Syndromic Surveillance Considerations for Chemical Agents

The CDC recognizes that the covert release of a chemical agent might not be easily identified. As with biological agents, identifying a covert release of a chemical agent will depend on alert healthcare professionals recognizing the situation as victims present. In addition to the cues associated with biological releases, there are some additional cues specific to chemical agent use. These include emission of unexplained odors by patients, rapid onset of symptoms after an exposure to a potentially contaminated medium, and a syndrome suggesting a chemical exposure.

The current practical limitations on biological agent detectors carry over to their chemical agent counterparts. They are primarily environmental sampling tools not designed to assist healthcare workers in diagnosis and treatment.

Categories of Chemical Agents

Based on type of effect, there are five major categories of chemical agents: blister, choking, blood, nerve, and incapacitation/riot control.

Unlike biological agents, which do not remain active in the environment for relatively long periods after delivery, chemical agents may. In terms of duration of potential effect and hazard target, chemical agents may be nonpersistent, in that they dissipate within a few hours. Nonpersistent agents are most dangerous to the lungs. Persistent agents remain active for up to a month on surfaces and are most dangerous to the skin.


Blister or vesicant agents are highly reactive chemicals that combine with proteins, DNA, and other cellular components to result in cellular changes immediately after exposure. Depending on the agent, signs and symptoms may manifest anywhere from 2 to 24 hours after exposure. Likely routes of exposure are inhalation, dermal contact, and ocular contact; ingestion is also possible.

Source: CDC, 2006d.
Examples Distilled mustard (HD), mustard gas (H), lewisite, mustard/lewisite, mustard/T, nitrogen mustard, phosgene oxide, sesqui mustard, and sulfur mustard
  • Burning, itching, red skin; prominent tearing, burning and redness of eyes; shortness of breath; nausea and vomiting
  • Signs: upper airway sloughing, pulmonary edema
  • No antidotes for mustards
  • For lewisite or lewisite/mustard mixtures: British Anti-Lewisite, if available
  • Thermal burn therapy, including ocular burns; supportive intensive care, including respiratory support
Notes Smell of garlic, mustard or onion on body, oily droplets on skin

Choking agents are delivered as gases; inhalation triggers the immune system. Fluids build up in the respiratory system, especially the lungs. Effects may be felt at once or delayed up to three hours.

Source: Medscape, 2010a.
Examples Phosgene, chlorine, diphosgene, chloropicrin, oxides of nitrogen, sulfur dioxide
  • Shortness of breath, chest tightness, wheezing, laryngospasm
  • Mucosal or dermal irritation/redness
  • Pulmonary edema; mucosal irritation (water solubility of agent good predictor of mucosal irritation)
  • ARDS/noncardiogenic pulmonary edema/infiltrate
  • No antidote
  • Management of secretions; O2 therapy
  • Consider high-dose steroids to prevent pulmonary edema (only found beneficial for oxides of nitrogen)
  • Treat pulmonary edema with PEEP to maintain pO2 >60 mmHg
Source: CDC, 2008.
  • Clusters of acute lung or GI injury (depending on exposure); circulatory collapse; shock; tracheobronchitis, pulmonary edema, necrotizing pneumonia if inhaled
  • Ingestions: nausea, diarrhea, vomiting, fever, abdominal pain
  • Inhalation: chest tightness, coughing, weakness, nausea, fever
  • No antidote
  • Supportive care
  • For ingestion: charcoal lavage

Blood agents are also intended for inhalation. They block the enzyme necessary for aerobic metabolism, depriving the red blood cells of oxygen and causing asphyxiation. Onset of symptoms is immediate—seconds to minutes.

Source: Medscape, 2010b.
Examples Hydrogen cyanide, cyanogen chloride
  • Moderate exposure: giddiness, palpitations, nausea, vomiting, hyperventilation, drowsiness, headache; metabolic acidosis, hypotension, pink skin
  • High exposure: immediate loss of consciousness, convulsions, death in 1–15 minutes
  • 100% O2 by mask or ET tube
  • Cyanide antidote kit:
    • Sodium thiosulfate injection: 12.5 g/50 mL (2 vials)
    • Sodium nitrite: 300 mg/10 mL (2 ampules)
    • Amyl nitrite inhalant: 0.3 mL (12 ampules)
  • Crush 0.3 mL ampul of amyl nitrite q1min and inhale vapor for 15–30 seconds until IV sodium nitrite infusion available
  • Following infusion of 300 mg or 10 mg/kg IV sodium nitrate, over 2–5 minutes, inject 12.5 g sodium thiosulfate IV over 10 minutes PRN; may repeat both injections at 1/2 original dose
Notes Bitter almond odor indicates cyanide

Nerve agents affect the transmission of nerve impulses, causing death by shutting down the respiratory centers in the brain and paralyzing the respiratory muscles.

Source: CDC, 2006a.
Examples Sarin, tabun, soman; organic pesticides
  • Moderate exposure: diffuse muscle cramps and tremors, runny nose, dyspnea, vision dimming, sweating; miosis, bronchial constriction, increased secretions, respiratory arrest, diarrhea
  • High exposure: as above, plus sudden loss of consciousness, convulsions, flaccid paralysis
  • Atropine (2 mg IV) every 5 minutes until effective
  • 2PAM chloride (600–1800 mg IM or 1 Gm IV over 20–30 minutes); maximum dose = 2 Gm over 1 hour
  • Diazepam or lorazepam for seizures if >4 mg atropine given
  • Ventilatory support

A woman walked into the showgirls’ dressing room 30 minutes before the first show of the evening. In the controlled chaos, no one noticed her enter or set the door lock. Her phone vibrated, signaling that her accomplice was going to throw the breaker for the lights in 10 seconds. The woman punctured the lid of a large food storage container and placed the container on the floor near the door. As the lights went out, she left the room, closing and locking the door behind her.

The thirty-five dancers in the dressing room panicked and in attempting to reach the door knocked over the container, dispersing sarin and causing the liquid to vaporize. The dancers began inhaling the agent. Several fell, and their skin was exposed to the remaining agent in liquid form. All of the dancers began experiencing the symptoms of moderate exposure, with those nearest the door having a more immediate, intense reaction.

Their screams alerted other casino employees, who found a note on the locked door calling casino dancers “Jezebels” and promising further “saran” attacks. Some employees called 911, while others broke down the door and began to assist their colleagues. Because not all of the agent had evaporated, some of the rescuers were also exposed and began to experience symptoms

First responders arrived and identified the situation as a sarin gas attack. Their assessment included the need to provide antidotes and possible ventilatory support for forty or more victims. Shortfalls to provide this care were readily apparent. While atropine and diazepam were readily available in their vehicle and from their base station in adequate quantities to treat the number of victims, 2PAM chloride was not.

The nearest hospital was notified, and it activated its disaster plan. However, it did not have adequate intensive care beds available to treat the number of victims anticipated to need ventilatory support.

The community EOC was notified. In accordance with the community plan, other hospitals were notified of the situation and alerted to the potential need to provide supportive care for a large influx of patients.

Previously identified sources for 2PAM chloride were contacted, and emergent delivery was made to the release site and the facilities poised to receive victims.


Incapacitation and riot control agents are designed to be non-lethal but can cause injury or death because self-preservation behaviors may be overridden or inhibited. Large numbers of victims will easily overwhelm the healthcare system.

Source: CDC, 2006c; Medscape, 2010c.
  • Incapacitation: BZ, LSD
  • Riot control: CS (“tear gas”), CN (Mace®)
  • Incapacitation: dizziness, dry mouth, sweating, tremors; tachycardia, hypertension; bizarre behavior
  • Riot control: runny nose and eyes, shortness of breath, skin burns
  • Incapacitation: as indicated, if injured; protection from further injury
  • Riot control: Flush eyes and/or skin; treat symptomatically

Decontamination of Victims of Chemical Agents

Removing the chemical agent from the victim’s person and clothing serves two purposes. It ends the victim’s exposure and limits injury to what has been received up to that time. It also significantly reduces the risk of exposure to healthcare workers.

Ideally, clothing should be removed and decontamination carried out before the victim is transported from the release site to the healthcare facility. Studies have shown that simply removing contaminated clothing can reduce the quantity of contaminant associated with victims by an estimated 75% to 90%. Having victims shower with tepid water and a liquid soap with good surfactant properties is widely considered the most effective method for removing the remaining hazardous substance from victims’ skin and hair. When the nature of the contaminant is known, the decontamination procedures can be adjusted to best remove the specific hazard (OSHA, 2005).

If clothing has not been removed and decontamination done prior to arrival at the healthcare facility, clothing removal and decontamination should be done before the victims are moved into the facility.

Personal Protective Equipment

The following guidelines apply when the receiving facility is not the release site, the identity of the substance is unknown, and initial decontamination is done at the receiving facility.

Minimum PPE for personnel involved in the decontamination process, including post-decontamination cleanup, is extensive. Respiratory protection includes a NIOSH-approved powered air-purifying respirator (PAPR) or a combination 99.97% high-efficiency particulate air (HEPA)/organic vapor/acid gas respirator cartridge (also NIOSH-approved). Body surfaces should be protected with double-layer protective gloves, a chemical resistant suit with suit openings sealed with tape, head covering and eye/face protection (if not part of the respirator), and chemical-protective boots (OSHA, 2005).

Minimum PPE for personnel involved in patient care after decontamination consists of normal work clothes and PPE, as necessary, for infection-control purposes.


Left: air-purifying respirator (APR). Right: powered air-purifying respirator (PAPR). (Source: OSHA.)


Correct selection and fit of an individual respirator is critical for worker safety and should be done prior to need. Initial and annual refresher training is recommended to maintain proficiency in applying, wearing, and removing the respirator. Consult your occupational health service for assistance in this process. This should be done by someone with expertise in the field.

Selection is based on fit to the face, to include accommodation of corrective and/or protective eyewear, comfort for a prolonged period, and the ability to speak and be heard.

Since fit is closely correlated to face size and shape, refitting should be done if significant weight and/or facial shape change occurs.

Source: OSHA, 2006.


Responding to an act of terrorism can provide a tremendous sense of satisfaction to healthcare providers. Knowing that one has made a significant difference to both victims and to the community as a whole is very rewarding. Previous training comes to the forefront of the mind and altruism provides the energy to convert knowledge into action.

Adrenalin will carry responders through the immediate period following the event. But the body and mind are not designed to sustain this level of stimulation for prolonged periods; when the individual’s threshold has been reached, the effects will begin to manifest themselves. Once the initial response to the event is over and the euphoria of having made a difference has faded, then the delayed effects will make their appearance, both in physical and psychological ways.

What Is Stress?

Stress is the term used to describe a variety of physiological and psychological stimuli that cause a physiological response. This was first described in 1936 by Hans Selye. In his research, he separated the physical effects of stress from other physical symptoms suffered by patients, observing that patients suffered physical effects not caused directly by their disease or by their medical condition. He termed this “general adaptation syndrome” and divided it into three stages:

  1. Alarm reaction, where the body detects the external stimulus
  2. Adaptation, where the body engages defensive countermeasures against the stressor
  3. Exhaustion, where the body begins to run out of defenses

Stress can have a major impact on the physical functioning of the human body. It raises the level of adrenaline and corticosterone in the body, which in turn increases the heart rate, respiration, and blood pressure and puts more physical stress on bodily organs. In the short term, this allows a person to perform at levels beyond their normal limits. But once exhaustion is reached, even the strongest motivation loses its effect (PW, 2011).

Types of Stress

Both victims and caregivers will show signs of stress. This can manifest as compassion fatigue, vicarious trauma, or burnout.


Compassion fatigue (CF) is the profound emotional and physical erosion that takes place when helpers are unable to refuel and regenerate (WHP, 2007). Caregivers for victims of terrorism must recognize that they need to take care of themselves so that they can continue to care for others. Likewise, peers need to look out for each other.

As a management function, supervisors have the responsibility to see that their subordinates are not only provided opportunities for breaks, but that they actually take them. In addition, supervisors must lead by example and model appropriate self-caring behavior.


For the caregiver, especially in an intense situation such as responding to a terrorist act, the phenomenon called vicarious trauma is often observed. Unlike direct or experienced trauma, vicarious trauma is the result of changes in a healthcare provider due to empathic engagement with victims (CERT, 2003). The very thing that motivates people to enter the healing field can, if not recognized and planned for, make them victims as well.

Among the physical manifestations of vicarious trauma are anorexia and direct GI symptoms such as nausea, stomach pain, and diarrhea. Especially if the person reacts to this by not eating or eating less than usual, fatigue and reduced energy can result. Paradoxically, insomnia and hyperactivity are also possible. Headache and chest pain may present.

Psychological signs may present as exaggerated forms of a person’s usual behavior or as reactions not usually seen, at least in the workplace. As the situation continues, these responses may become more frequent and/or stronger and/or requiring less and less to trigger them,

Irritability and outright anger are common early signs, as is denial. Blaming may be directed inward, outward at specific individuals or institutions, or generally. Feeling stunned, overwhelmed, or helpless may lead to isolation or withdrawal. Sadness can intensify to grief and then depression. Mood swings, even in the absence of a diagnosed illness, may present with accompanying physical manifestations. Problems with memory or concentration can complicate the caregiver’s ability to function at their usual level at a time when their acuity is most needed.

At a time when support given to and received from ones personal and professional circles are of paramount importance, issues with interpersonal and/or professional relationships may suffer, as the caregiver becomes increasingly inwardly focused.

The pain caused by all of these physical and psychological factors can lead to self-medication with therapeutic and/or recreational substances.

The first and perhaps most important tactic to employ to minimize the impact of vicarious trauma is to be aware that it will occur, eventually and to some degree, to everyone.


Although commonly used interchangeably with the terms compassion fatigue and vicarious trauma, burnout is a term that has been used a great deal to describe the physical and emotional exhaustion that workers can experience when they have low job satisfaction and feel powerless and overwhelmed at work. Burnout does not necessarily mean that one’s view of the world has been damaged or that one has lost the ability to feel compassion for others (WHP, 2007).

Responding to Stress

Know your own personal stress triggers and how they manifest in your thinking and behavior. Use reflection on past situations to attempt to identify them yourself. If there is a trusted person in your circle, ask for his/her insight. Accept that you may not like what you discover, then use that lack of satisfaction as a starting point for change.

Work on incorporating healthier responses to stress. This may be a personal project or may require outside assistance. At a minimum, it can take 30 days to incorporate one simple change. Celebrate your successes. Treat setbacks (and they will occur) as a learning opportunity and an opportunity to start over.

Go back to the basics. Strive for an adequate intake of nutritious food, with comfort foods as treats, not essential components. Ensure an adequate fluid intake to maintain hydration and electrolyte balance.

Take periodic breaks as the situation allows. When told to “take a break,” do so. Remove yourself at least mentally from the center of activity. Sleep when the situation allows. A 10-minute “power nap” can make a big difference in your energy level. Tell someone what you are doing and ask them to wake you if your internal alarm clock is fallible.

In the event of a terrorist attack, be realistic as you assess your reactions and those of your colleagues and patients. Understand that abnormal responses to abnormal situations are normal. Consciously check in with yourself periodically to see how you are doing. Use your coping strategies. Watch out for your co-workers.

In the aftermath of responding to an act of terrorism, the most important task is to accept that things will never be the same and that you have been affected as a person and a professional. Take advantage of resources available in your workplace and community to help you move forward from what you have experienced. Don’t wait for help to come to you; seek it out.


Well-thought-out disaster plans should provide guidance on how individual healthcare providers and specific institutions will rapidly and effectively transition from “business as usual” to providing appropriate care to large numbers of victims of a natural or man-made disaster. While no plan can anticipate and spell out responses to every conceivable and inconceivable situation, there needs to be enough consideration given to either provide specific direction or serve as a starting point for rapid adaptation of what information is presented.

Personal Preparedness

In order to be able to respond effectively to an act of terrorism in your professional capacity as a healthcare provider, you must do everything possible to ensure that personal responsibilities have already been met. This is not to imply that concern for your loved ones will vanish because you have a household disaster plan in place. But the knowledge that you have done as much as possible to prepare should assist you in focusing on the workplace situation.

There are a variety of community resources available to assist in disaster preparation, as well as a variety of formats. Standardized nationwide classes offered by the American Red Cross and the Community Emergency Response Team program are a great starting point for preparing your own household and may be a doorway into community involvement as well (see “Resources” at the end of the course). Look at your own situation and identify what resources in your area are available that meet your and your household’s needs. Then enroll yourself and your household in a class or begin your individual preparation.

Select someone out of the immediate area to serve as a contact to “check in” with in time of emergency. This person should have both the maturity and availability to accept this responsibility. Get that person’s agreement ahead of time to act as your point of contact, and be sure everyone in your household knows how to reach the contact. Offer to reciprocate for your contact person.

Even if you never need to implement your household disaster plan because of a terrorist incident, you will be well prepared to deal with the more likely scenario of a natural disaster. General disaster preparedness translates directly to being ready for a terrorist incident, and vice versa.

Professional Preparedness

In the case of a terrorist attack, it is likely that you will be at work beyond your normal shift due to increased patient load. If the nature of the attack calls for quarantine or lock down, you may not be able to leave, nor will replacements be allowed to report for work. The emergency survival kit you may already have in your vehicle may not be accessible, nor will someone be able to bring you a “care package” from home, at least in the initial hours. Thus, you should keep a personal “survival kit” in a secure location in your workplace.

  • Contact lens case and solution and current prescription spectacles
  • Batteries for hearing aid
  • Several days’ supply of any required or anticipated medication
  • Extra socks and underwear
  • Personal care products (deodorant, shampoo, oral hygiene products)
  • Feminine hygiene or urinary care products, if needed
  • Outlet charger for cell phone
  • Individual packets of water flavoring or electrolyte replacement products
  • Ear plugs and an eye shade

Think outside the box, that is, beyond what you need for a normal shift. Ask yourself “What would keep me from being effective if I didn’t have it?” Remember to rotate anything with an expiration date.

Keep a small supply of nonperishable, ready-to-eat food items in your workplace as well. Look for a good balance of nutrients for your individual needs. Include comfort food as well as necessities, but concentrate on fueling your body, not soothing your mind. Check “use by” dates and rotate food items and beverages to maintain freshness.

Read or scan your facility disaster plan. The level of familiarity you need will depend on your position in your facility. Concentrate on understanding what your role would be in the event victims of a terrorist act were to present at your facility. Ask questions if there is something that is ambiguous or unclear. If something appears to be absent, use your chain of command to move your concern forward. Be tactful and mission-focused in articulating your observation. Consider offering to assist with revising or updating the plan. That makes you part of the solution, not a finger-pointer.

Read the section of the disaster plan that most closely spells out the role your unit or department would play in treating victims of terrorism. All of the above comments apply to this as well.

Periodically run a “mental disaster drill,” identifying how you anticipate you would participate in the event of a terrorist incident. Be an active participant in unit or facility safety drills and in the debriefing afterwards. If your unit or workplace maintains alert rosters or telephone trees, ensure that your contact information is current.

Facility Preparedness

It is beyond the scope of this course to describe in detail the steps a healthcare facility should take to prepare to receive victims of a terrorism attack. The following guidelines are presented for development and/or review of a program designed to incorporate recognized best practices, take into consideration the needs of and resources available in the local and wider community, and provide the basis for dialogue in developing an interdisciplinary approach that will be effective for a facility’s likely role.

Much of the following material is taken from “OSHA Best Practices for Hospital-Based First Receivers of Victims from Mass Casualty Incidents Involving the Release of Hazardous Substances” (OSHA, 2005). Although some of the material is clearly designed for an inpatient-care setting with a complex organizational structure, it has applicability for a variety of healthcare facility types.

If your practice is other than hospital-based, as you read, mentally edit in the appropriate workplace designation that best describes your setting and consider what adaptations your facility would need to make.


The most practical way to develop or review your plan is to gather both individuals who will develop polices and those who will be responsible for implementing them and walk through a scenario in extreme detail. The administrative personnel will most likely have broader and deeper knowledge of both the facility’s resources and its role in the greater community response. The hands-on healthcare providers’ greatest contribution is usually the detail focus: they have the practical experience to ask and answer the critical “How will we…?” questions that move a plan from concept to action.

Ask yourself, What other things does our facility need to consider to ensure that as many questions are asked and answered in advance of the need?

Review Methodologies

Facilities should consider their anticipated roles in the case of terrorist actions of varying types and sizes and how they would coordinate activities with other emergency response agencies and facilities within the community.

One very basic way to model how your facility would follow its existing plan (or what it would need to consider in creating or revising a plan) is to create a victim and follow him or her from arrival to discharge. This is called tracer methodology and should be familiar to anyone who has had a recent visit from a government or accreditation survey team. In this instance, you may define “discharge” as occurring when the patient is able to safely enter the mainstream care system or all the way to ultimate discharge from the facility.


Several staff nurses are part of an interdisciplinary working group asked to review their facility’s disaster response plan. The group includes direct-care providers as well as middle and senior managers. Initially, each person reviews the part of the plan that relates to his or her occupation and likely role in the event the plan is activated. Then each occupational specialty group meets and prepares a summary report. One of the staff nurses is selected to present the nursing team’s report.

In an effort to bring fresh eyes to a document that has been in place for several years, each team is then given a part of the plan out of their usual role. Nursing is asked to review the security portion. They discover that the plan does not reflect the opening of the new outpatient surgery center. Approximately 5,000 cases per year are done in these ORs. There are now additional doors for patients and staff, a small loading dock, and two corridors connecting to the main building. Prior to the opening of the center two years ago, there was an open house and extensive media coverage. In addition, every year Perioperative Nurse Week is observed with self-guided tours of the entire center for the public.

The team realizes that a substantial number of community members now potentially have intimate knowledge of how to access the hospital through outpatient surgery. The nursing team identifies several potential physical security issues to be addressed. They draw a sketch map of the new footprint, identifying the additional doors that need to be secured or monitored. In addition, they recommend that future open houses be limited to guided tours and do not allow unrestricted access to the entire center.

Regular Plan Review

Activation of the disaster plan moves the facility from normal operating mode to responding to the crisis. The plan should be reviewed at least annually and whenever significant changes in structure or operation are made. Consider things like the date of the last full or partial revision, currentness of contact rosters, and changes in organizational structure that would have an impact on the plan.

  • Does your facility have either an event (annual performance review) or date (semiannual time change) trigger to verify employee contact information for telephone trees?
  • Is there a clearly stated responsible staff position and alternate to activate the plan for all situations, including evening and night shifts, weekends, and holidays?
  • Are staff preassigned by name and/or role to specific areas or tasks? Does each staff member know what his or her role and duty station would be? Will whole areas or units have their role change?

“Isolation” and “lockdown” elements of a plan describe how your facility will allow access to those presenting for care while simultaneously protecting for their safety and that of the caregivers and the facility infrastructure as a whole. The methods range from guards with keys at locked doors to sophisticated keycard systems controlled at a central command center. Hospitals need a method to control access if situations suggest that an unruly crowd will force its way into the hospital.

Site security personnel assist in maintaining order and directing traffic around the decontamination facility and the hospital entrances. This serves to correctly direct contaminated individuals, to prevent other staff from becoming exposed, to protect equipment, and to ensure contaminated victims do not bypass the decontamination area or enter the ED without passing inspection.

Consider how many access points exist in your facility. Some will be obvious, such as doors marked for staff, patient, and visitor entrance and exit. Others are subtler, such as delivery doors, loading dock areas, and tunnels. The combination of insider knowledge and desperation could turn these into the weak points in your perimeter.

  • How many checkpoint personnel will be needed to monitor these points?
  • Does your facility have an adequate number of security staff, or will you need to designate and train other workers to augment them?
  • Which areas require a fully trained security staff member and which could be covered by someone with limited security training?
  • Are there adequate quantities of in-language signage to direct victims, families, media, and others to appropriate areas?
Predecontamination Triage

In this area contaminated individuals are distinguished from other patients arriving at the hospital by identifying symptoms and a victim’s proximity to the known agent release. In addition, staff assigned to this area identify patients who require immediate stabilization before they enter the decontamination system.

Remember that the need for immediate life-saving treatment supersedes decontamination.

  • Are emergency treatment supplies needed for this area packaged in such a way that they can be quickly accessed by staff wearing PPE?
  • Are they packaged in quantities that will meet the likely number of victims while not causing excess expense. (Remember, once items such as medications and most supplies enter this area, they are lost to the system.)

Plan in advance how you will learn as much as possible (as soon as possible) about the number of victims, the contaminant, and associated symptoms. Previous arrangements with first responder organizations can improve the timeliness and quantity of information received.

  • What medical monitoring (e.g., vital signs) will need to be done on personnel before they enter potentially hazardous areas, such as predecontamination triage or decontamination?
  • Where is PPE stored? Are adequate levels of all items readily available on site? Do staff know where to draw PPE items?
  • Is a plan in place to assist victims (ambulatory and non-ambulatory) in removing contaminated clothing and securing personal property as soon as possible (within minutes of arrival)?
  • Are approved hazardous waste containers available and is an area identified for them that is isolated outdoors so that contaminated items are not a continuing source of exposure?
  • How will staff inspect or survey victims to evaluate the effectiveness of decontamination and guide decontaminated victims to the medical treatment area or back to the decontamination area?
  • How will decontamination equipment itself be decontaminated or safely discarded if disposable?
  • Is there a method to remind staff to remove PPE and decontaminate themselves before leaving the area?
Hospital Post-Decontamination Zone

After victims are inspected or surveyed and found to be free of contamination, a second, purely clinical, triage is conducted.

  • Given that a larger number of potentially more seriously injured victims are involved, how will emergency department staffing be augmented to accommodate this patient increase?
  • How could staff be diverted from their usual role to meet this need?
Wastewater Management

Wastewater from decontamination showers can contain low-level concentrations of the substance(s) with which victims are contaminated. How will the facility manage the wastewater generated during the decontamination process? This can range from complete water retention in a storage unit with eventual controlled removal to uncontrolled release into a parking lot or storm drain. Whatever process is built into the plan, it needs to be coordinated with local authorities and supporting contractors.

Solid Waste Management

How will the facility manage the solid waste generated during victim decontamination activities? As it is hazardous waste, it can be managed by following the hospitals’ existing hazardous waste management procedures. But can the system readily adapt to the sudden dramatic increase in this quantity of “red-bag” waste?

Authorities might request that certain types of waste be retained as evidence. In that case, the agency will provide instructions on handling the waste. How will staff be notified what they need to preserve versus what can de discarded?

Morgue Services

Will bodies of the deceased require special handing due to the nature of the incident?


As unthinkable as the intentional attack on a patient-care facility may be, the precedent does exist. As recently as February 2010, a hospital in Karachi, Pakistan, was bombed as it was providing care to victims of an earlier attack. Thus, some thought must be given to this situation.

For a targeted healthcare facility to continue to function, several criteria would need to be met. The physical integrity of at least part of the facility would need to be sufficiently intact and free of contamination. In addition, the intact area would need to be suitable for providing care or easily adaptable for that purpose. There would need to be uninjured workers in sufficient numbers and in a useful occupational mix to provide care. If the enhanced level of protective wear to function as first receivers was not stockpiled at the facility, the facility would need to obtain it from a source in the community.


The Health Alert Network (HAN) is a strong national program providing vital health information and the infrastructure to support the dissemination of that information at the state and local levels and beyond. All 50 states, 3 large city health departments, 3 county health departments, 8 territories, and the District of Columbia are connected to HAN, as are some health organizations and major hospital networks. A vast majority of the state-based HAN programs have over 90% of their population covered under the umbrella of HAN.

HAN ensures that each community has rapid and timely access to emergent health information provided by a group of highly trained professional personnel using evidence-based practices and procedures for effective public health preparedness, response, and service on a 24/7 basis.

HAN Messaging System

The HAN Messaging System currently directly and indirectly transmits information to over one million recipients.

Message types are categorized by the level of urgency of the information.

  • Health Alert: conveys the highest level of importance; warrants immediate action or attention
  • Health Advisory: provides important information for a specific incident or situation; may not require immediate action
  • Health Update: provides updated information regarding an incident or situation; unlikely to require immediate action
  • Info Service Message: provides general information that is not necessarily considered to be of an emergent nature

For health emergencies that are unique to the state, a state or county officer may also send out alerts.

The Health Alert Network helps to address issues created by our increasingly mobile society and pressures on local and state health infrastructures to be prepared to deal with public health emergencies, including terrorism response. Rapid and efficient communication systems help to ensure that critical events do not go undiagnosed or unreported while spreading to other localities (NSHD, 2007).

Local healthcare providers may find themselves on the frontline—in a position to notice unusual case patterns or a sudden increase in similar cases in the emergency room. Their facilities need to be able to respond quickly in such situations. The HAN is intended to help by providing ongoing surveillance activities to quickly identify potential health threats, laboratory capability to perform testing to determine the threat agent, the ability to conduct disease investigations, effective protocols for reporting incidents and sharing information, and efficient emergency communications among all involved parties (NSHD, 2007).

Subscribing to HAN Alerts

HAN members are identified and tracked in a secure database maintained by Public Health Preparedness. Subscription is free but does require an email address. Enrollees receive a user name and password and establish a personal profile to facilitate receipt of alerts. When an alert is received, the subscriber logs on to a secure website to retrieve the message and obtain links to any additional information (NVSBN, 2007).

Interested healthcare professionals should go to the Health Alert Network website for further information and links to the signup and login processes (see “Resources” below).


As part of the annual review of the facility disaster management plan, the team notes that only the CEO, COOs for nursing, medical staff, and laboratory and senior infection preventionist have Health Alert Network (HAN) accounts. Queries reveal that the majority of individuals at and below senior management are unaware of the program.

The review committee conducts an education initiative to encourage wider participation. They send information out in the next facility electronic newsletter and have the infection prevention team do a multi-day, multi-shift staffed table display in the cafeteria. In addition, they hold a drawing for coffee cards; to enter, employees must correctly answer a question with a response only found on the website.


Center for International Security and Cooperation (CISAC). (2002a). Nuclear terrorism: risks and realities, radiation fact sheet. Freeman Spogli Institute for International Studies, Stanford University. Retrieved November 27, 2011, from

Center for International Security and Cooperation (CISAC). (2002b). Understanding nuclear terrorism: understanding the risks and realities of nuclear terrorism. Freeman Spogli Institute for International Studies, Stanford University. Retrieved November 28, 2011, from

Center for Nonproliferation Studies (CNS). (2008). CW terrorism tutorial. Retrieved November 26, 2011, from

Centers for Disease Control and Prevention (CDC). (2008). Emergency preparedness and response. Ricin. Retrieved November 27, 2011, from

Centers for Disease Control and Prevention (CDC). (2007a). Emergency preparedness and response. Bioterrorism agents/diseases. Retrieved November 28, 2011, from

Centers for Disease Control and Prevention (CDC). (2007b). Smallpox vaccination/vaccine overview. Retrieved November 28, 2011, from

Centers for Disease Prevention and Control (CDC), Healthcare Infection Control Practices Advisory Committee (HICPAC). (2007c). 2007 guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings. Table 3: Infection control considerations for high-priority (CDC Category A) diseases that may result from bioterrorist attacks or are considered to be bioterrorist threats. Retrieved November 25, 2011, from

Centers for Disease Control and Prevention (CDC). (2006a). Emergency preparedness and response. Sarin. Retrieved November 27, 2011 from

Centers for Disease Control and Prevention (CDC). (2006b). Emergency preparedness and response. Botulism facts for health care providers. Retrieved November 26, 2011, from

Centers for Disease Control and Prevention (CDC). (2006c). Emergency preparedness and response. Facts about riot control agents, interim document. Retrieved November 26, 2011, from

Centers for Disease Control and Prevention (CDC). (2006d). Emergency preparedness and response. Sulfur mustard (mustard gas). Retrieved November 27, 2011 from

Centers for Disease Control and Prevention (CDC). (2005a). Radiological terrorism: emergency management pocket guide for clinicians. Retrieved November 28, 2011, from

Centers for Disease Control and Prevention (CDC). (2005b). Acute radiation syndrome: a fact sheet for physicians. Retrieved November 25, 2011, from

Centers for Disease Control and Prevention (CDC). (2003a). Radiation measurement fact sheet. Retrieved November 25, 2011, from

Centers for Disease Control and Prevention (CDC). (2003b). Recognition of illness associated with exposure to chemical agents—United States, 2003. Morbidity and Mortality Weekly Report (MMWR), 52(39), 938–40. Retrieved November 26, 2011, from

Community Emergency Response Team (CERT). (2003). Instructor guide. McLean, VA: Human Technology, Inc.

Department of Defense (DOD). (2007). Department of Defense dictionary of military and associated terms. Joint Publication 1-02. Retrieved November 26, 2011, from

Department of Homeland Security (DHS). (2003). Working Group on Radiological Dispersive Device (RDD) Preparedness/Medical Preparedness and Response Working Sub-Group. Retrieved November 26, 2011 from

Federal Bureau of Investigation (FBI). (n.d.). Terrorism 2002–2005 (2nd ed.). Retrieved November 26, 2011, from

Federal Emergency Management Agency (FEMA). (2007). General information about terrorism. Retrieved November 25, 2011, from

Green, WG III. (2006). Mass casualty incident: the Virginia model. Paper presented at the 2000 Disaster Medical System Conference. Retrieved November 25, 2011, from

Jamison DT, Breman JG, Measham AR, et al. (Eds.). (2006). Disease control priorities in developing countries (2nd ed.). Washington, DC: World Bank. Retrieved November 27, 2011, from

Mayo Clinic. (2011). Treatment for smallpox. Retrieved November 25, 2011, from

MedScape. (2010a). Lung-damaging agents, phosgene treatment, and management. Retrieved November 27, 2011, from

MedScape. (2010b). Cyanide antidote kit. Retrieved November 25, 2011, from

MedScape. (2010c). Toxicity, hallucinogens: LSD treatment and management. Retrieved November 27, 2011, from

Nevada State Board of Nursing (NVSBN). (2007). APNs encouraged to participate in Nevada Health Alert Network. Nursing News, 14. Retrieved January 23, 2008, from

Nevada State Health Division (NSHD). (2007). Public Health Preparedness Program. Health Alert Network. Retrieved January 22, 2008, from

Oak Ridge Institute for Science and Education (ORISE). (2000/2002). Guidance for radiation accident management. Retrieved November 27, 2011, from

Occupational Safety and Health Administration (OSHA). (2006). Fit testing procedures—mandatory. Retrieved November 28, 2011, from

Occupational Safety and Health Administration (OSHA). (2005). OSHA best practices for hospital-based first receivers of victims from mass casualty incidents involving the release of hazardous substances. Retrieved November 25, 2011, from

PsychologistWorld (PW). (2011). What is stress? Retrieved November 26, 2011, from

United States Department of Health and Human Services (USDHHS). (2010). Radiation Emergency Medical Management (REMM). Initial event activities/hospital activities/suggested supply list for decontamination of victims in the emergency department. Retrieved November 26, 2011 from

United States National Library of Medicine (USNLM), PubMed Health. (2011). Plague. Retrieved November 27, 2011, from

Wolbarst A, Wiley A, Nemhauser J, et al. (2010). Medical response to a major radiologic emergency: a primer for medical and public health practitioners. Radiology, 254(3), 660–667. Retrieved November 26, 2011, from

Workshops for the Helping Professional (WHP). (2007). Compassion fatigue Q&A. Retrieved November 25, 2011, from

Back to Top
Wild Iris Medical Education