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Bioterrorism Preparedness and Response for Healthcare Professionals

Online Continuing Education Course

Course Description

5-hour CEU course for nursing and EMS personnel. Emergency and facility disaster preparedness planning for healthcare response to a terrorist attack involving biological, chemical, or nuclear weapons. Covers methods of protection for healthcare providers and patients in a mass casualty incident (MCI).

Course Price: $35.00

Contact Hours: 5

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Bioterrorism Preparedness and Response for Healthcare Professionals

LEARNING OUTCOME AND OBJECTIVES:   Upon completion of this course, you will be better prepared to protect and care for yourself and your patients during emergencies relating to acts of terrorism. Specific learning objectives include:

  • Define the terms “terrorism,” “terrorist attack,” “weaponization,” “weapons of mass destruction (WMDs),” and “syndromic surveillance.”
  • Distinguish between a terrorist attack, a criminal act, and a mass casualty incident.
  • Describe types of terrorists and terrorist attacks.
  • Review signs and symptoms of exposure to and emergency treatment for patients exposed to nuclear, biological, and chemical agents.
  • Describe appropriate personal protective equipment (PPE) to be used when treating patients potentially or actually exposed to nuclear, biological, and chemical agents.
  • Identify steps in developing a personal and facility disaster preparedness plan for terrorist attacks.
  • Discuss different forms of stress response, including coping strategies.
  • Explain the Health Alert Network (HAN).


Violence and warfare as a 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. Some of humanity’s earliest efforts at pictorial or language-based records deal with battles.

Formal histories, personal documents, and stories 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. While there were exceptions to this, there was also a taint associated with the targeting of civilian targets.

Until the beginning of the twentieth century, advances in weaponry focused on improving existing conventional technologies. It was only after chemical weapons 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 public, restricted to a remote battlefield location.

This worldview changed for some nations before it did in the United States. However, the bombing of the Murrah Federal Building in Oklahoma City in 1995 and the events of September 11, 2001, forced Americans to confront the reality that both the nation and individual citizens are potential targets of terrorists. More recently, the 2009 attack at a Fort Hood, Texas, medical facility and the explosion at the 2014 Boston Marathon finish line have served as continuing reminders of public vulnerability.

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. Nevertheless, it would be equally counterproductive for either a healthcare provider or healthcare facility to deny the threat and do nothing to prepare for such an eventuality.


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 appear 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 Terrorism?

In 1992, the United Nations proposed a definition of terrorism, which describes it as “an anxiety-inspiring method of repeated violent action, employed by (semi-)clandestine individual, group, or state actors, for idiosyncratic, criminal, or political reasons, whereby—in contrast to assassination—the direct targets of violence are not the main targets” (TR, n.d.).

Elements of this definition have carried forward into more contemporary versions:

  • 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, 2014).
  • The Department of Defense (DOD) defines terrorism as “the unlawful use of violence or threat of violence, often motivated by religious, political, or other ideological beliefs, to instill fear and coerce governments or societies in pursuit of goals that are usually political” (DOD, 2015).
  • In the U.S. Code of Federal Regulations, 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.).

Recurring elements within these definitions include:

  • The use of force or violence
  • The creation of fear among the public
  • The intent to coerce some sort of action
  • The decision to act outside the law

The word terrorism can convey certain theoretical and possibly distant qualities. Perhaps the ism suffix, having a sibilant sound, brings to mind a concept to be discussed in a classroom or debated in a coffee shop. The term terrorist attack, with its hard t and k sounds, however, conjures up a completely different notion, bringing the word from discussion into action.

Terrorist attacks are by their nature criminal acts, as the above definitions indicate, but a crucial difference lies in the motivation of the perpetrators. Unlike strictly criminal acts, which may also pose a threat of personal injury or loss of property of some sort, terrorist attacks generally reflect “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, 2014).


A mass casualty incident (MCI) is a situation “which generates more patients than available resources can manage using routine procedures” (Green, 2006). The key factor is the relationship between the number of casualties generated and the capabilities of the receiving facility or facilities.

Examples of MCIs include:

  • Multiple-vehicle accidents, such as the pileups caused by thick ground fog (tule fog) in California’s Central Valley
  • Train derailments, such as the 2015 incident in Pennsylvania, in which 8 people were killed, 11 people critically injured, and over 200 ed less serious injuries
  • Tornado outbreaks, such as the 84 confirmed tornados over four days in April 2014, which killed 35 and injured more than 200

A second, less-frequently used term is multiple casualty incident. Although superficially similar to a mass casualty incident, this term carries a different meaning for first responders and first receivers of trauma victims. Unlike a mass casualty incident, a multiple casualty incident:

  • Can be managed with heightened response (including mutual aid, if necessary) by a single EMS agency or system
  • Typically will not overwhelm the hospital capabilities of a jurisdiction and/or region but may exceed the capabilities for one or more hospitals within a locality
  • Usually produces a short, intense peak demand for health and medical services, unlike the sustained demand typical of a mass casualty incident
    (CT DPH, n.d.)

Terrorists usually select targets that will also produce large numbers of casualties, so it is safe to assume that most terrorist attacks will also be mass casualty incidents that affect healthcare facilities as described above. This means that healthcare providers and facilities will have to change the way they normally practice to respond appropriately to an act of terrorism.

When dealing with this or any other acronym, it is also important to be sure that everyone is using the same meaning for the phrase.

Types of Terrorists and Terrorist Attacks

In seeking to understand terrorism, there are various characteristics of the actors (terrorists), their targets, and the nature of their attacks.

(Note: The following examples are based on nonclassified information available to the public at the time this course was written.)


Many factors can influence the type and magnitude of a terrorist attack. The number and organization of the actual operators and the degree of local and remote support available to them often has a significant effect on both the ability to plan and carry out an attack and the degree to which the actual attack matches the plan.

Number of Operators

The September 11 multi-pronged attack on the World Trade Center, Pentagon, and Capitol is an example of effectively organizing, planning, and executing a terrorist attack. The multiple attackers were provided with adequate external financing to devote time and effort in order to plan their actions and to acquire the necessary skills to carry out their plans. This fits the description of a highly organized group with strong financial and political support.

The placement of the pressure cooker improvised explosive devices at the finish line of the 2013 Boston Marathon by two brothers is an example of the actions of a local cell. Their financial and logistical support was limited to themselves and their immediate circle. While they were influenced by actions occurring in other parts of the world, they had no tangible assets beyond their own.

A classic example of a lone operator is the Army psychiatrist at Fort Hood who shot and killed 12 fellow soldiers, the unborn child of one his victims, and a civilian physician’s assistant and also wounded 30 others. He was apparently also influenced by actions outside of the United States but acted alone in planning and carrying out his attack.

Origin of Operators

Referring to terrorism as “domestic” or “international” differentiates between both the location of the terrorist act and the place where the operators planned, trained, or obtained materials related to the attack.

The U.S. Code defines international terrorism to include activities that “occur primarily outside the territorial jurisdiction of the U.S., or transcend national boundaries in terms of the means by which they are accomplished, the persons they appear intended to intimidate or coerce, or the locale in which their perpetrators operate or seek asylum.” Domestic terrorism means activities that “occur primarily within the territorial jurisdiction of the U.S.” (FBI, n.d.). For instance:

  • The bombing of the Murrah Federal Building in Oklahoma City was an act of domestic terrorism because those responsible were (and had been for about 10 years) U.S. residents at the time of the attack.
  • The events of September 11 can be considered international terrorism because, although the targets were in the United States, the perpetrators were foreign nationals who planned, trained, and were supported from outside the country.


The relative “hardness” of a target refers to its level of protection (physical structure, security personnel, and/or access controls).

A hard target is one that is heavily protected and would be difficult to penetrate by either brute force or infiltration. For example, in the aftermath of the September 11 attacks, both the physical structure and access criteria for commercial airliner cockpits 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, victims of such an attack 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 may be flooded with both actual victims and people who are not affected but believe they have been.

In addition to the blatancy of the attack, acts of terrorism may be considered with regard to timing or sequencing.

The simplest sequence of a terrorist act is the stand-alone primary attack. The terrorists plan and carry out their act without any apparent rehearsal, possibly claim responsibility, and then either disappear or are engaged by authorities. The Fort Hood shooting is such an action. While in hindsight, the perpetrator left a trail of clues that pointed toward his eventual action (such as his acquisition of weapons and increasing his competency in using them), there was no practice attack.

A practice attack (dry run or rehearsal) gives the terrorist or terrorists opportunities to identify and correct flaws in their plan. The drill may be limited to one or more elements of the actual attack or may be a full-on dress rehearsal. In October 2013, the members of the commercial airline community indicated concern over what crew members interpreted as possible probes to determine weaknesses in in-flight security measures (U.S. Airline Pilots Association, 2013).

Given sequential consideration, the idea of a secondary attack followed by the primary attack may appear inherently contradictory. But in actual practice, it is especially malicious. The chronologically first but conceptually secondary attack triggers an interagency response (law enforcement, fire protection, and emergency medical response), which draws first responders and onlookers to the area, thus setting the scene for the attack that is the primary goal of the terrorists. A sequenced attack has several implications:

  • It is a casualty force multiplier, increasing the number of dead and injured.
  • It turns first responders into casualties, simultaneously increasing the number of victims and removing first response assets (both personnel and material) from service.
  • It raises the negative energy of the scene and may serve as a conscious or subconscious distractor, as both victims and responders wonder if there might be one or more additional attacks in the offing.

Weapons of Mass Destruction (WMDs)

According to the DOD (2015), WMDs are:

Chemical, biological, radiological, or nuclear weapons capable of a high order of destruction or causing mass casualties, and excluding the means of transporting or propelling the weapon where such means is a separable and divisible part from the weapon.

Over the years in the United States, there has been an evolution in the terminology used to refer to WMDs.

  • In the 1950s the most common term was “ABC” (atomic, biological, chemical).
  • During the Cold War, “NBC” (nuclear, biological, chemical) became the abbreviated version.
  • Toward the end of the twentieth century, an R (for radiological) was added, with the introduction of “dirty” (or radiological) bombs.
  • The E (standing for “enhanced” or improvised explosive devices) is a new-millennium upgrade.

The acronym B-NICE, from an early Community Emergency Response Team (CERT) manual, is an ironic but effective memory aid (CERT, 2003).

  • Biological weapons
  • Nuclear weapons and radiological dispersive devices (RDD)
  • Incendiary devices
  • Chemical weapons
  • Explosive weapons

The newer CERT mnemonic CBRNE realigns the categories but in a possibly less catchy order (CERT, 2011).

  • Chemical
  • Biological
  • Radiological
  • Nuclear
  • High-yield Explosives

The associated term weaponization has slightly differing meanings, depending on the context.

  • When used by the military, it means “to concentrate or alter a process, pathogen, or chemical so that it can be used as a weapon.”
  • In the framework of terrorism, the meaning broadens to include the adaptation of a non-weapon “for use as a weapon—e.g., shoes, box cutters, shoelaces, chopsticks, coins.”
    (SMD, 2012)

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

However, if a “combined” weapon (one incorporating two or more types of WMDs) is known or suspected to have been used, caregivers should consider the need for personal protective equipment (PPE) and the requirement to decontaminate the victim prior to or concurrent with treatment.


Nuclear or radiological weapons are the newest member of the WMD “family.” As an offshoot of the twentieth-century nuclear age, they are extremely technology dependent. Creating a nuclear WMD requires a high degree of scientific knowledge (or the ability to interpret and apply information available on the Internet) as well as access to specific materials and facilities.

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

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

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.


Both nuclear weapons and radiological dispersive devices have several similarities:

  • They have the ability 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 on the public fear of anything associated with nuclear use or radiation.
  • Caring for victims triggers the consumption of vast amounts of personnel and material resources to decontaminate casualties and clean up contaminated debris.

They differ in the type of nuclear material and required technology:

  • A true nuclear weapon requires the logistical and financial support to acquire the materials and the skill to create and deliver the weapon, in particular, access to weapons-grade plutonium or uranium-238. These complex factors may put this type of attack beyond the range of all but 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 terrorist groups.

What Is Ionizing Radiation?

Ionizing radiation is energy in the form of waves or particles that has enough force to remove electrons from atoms. It is often referred to simply as “radiation.” One source of radiation is the nuclei of unstable atoms. As these radioactive atoms (also referred to as radionuclides or radioisotopes) seek to become more stable, their nuclei eject or emit particles and high-energy waves. This process is known as radioactive decay (U.S. EPA, 2007).

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. The nuclear materials used in diagnostic or interventional medical care are forms of ionizing radiation.


How radiation is expressed is determined by the relationship of its amount to another factor. There are two measurement systems in use, the conventional system and the Système International d’Unités (SI). The conventional system is generally used in the United States.

What Is Being Measured Measurement System
Sources: CDC, 2014f; Wolbarst et al., 2010.
Radiation given off by a radioactive material Conventional: Curie (Ci)
SI: Becquerel (Bq)
Conversion: 1 Ci = 3.731010 Bq
Radiation dose absorbed by a person Conventional: Rad
SI: Gray (Gy)
Conversion: 1 rad = 0.01 Gy
Biologic risk of exposure to radiation Conventional: Rem
SI: Sievert (Sv)
Conversion: 1 rem = 0.01 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 patients’ bodies, 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 meters, colloquially known as “Geiger counters,” identify the presence of radiation in the physical environment or on the surface of or within victims. They are used during triage and decontamination of victims.

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

The second type of measuring device is a personal dosimeter, and it is part of the personal protective equipment 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 wearers when they are 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.

Film badge dosimeter, ring badge dosimeter, and real-time dosimeter.

Dosimeters: film badge (left), ring badge (center), and real-time (right). (Sources: OSHA and U.S. DHS.)

What Are the Effects of Radiation?

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 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 and cutaneous radiation syndrome (CDC, 2014a, b, e).

Acute Radiation Syndrome (ARS)

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 (early) 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. During the manifest illness stage, the patient begins to experience symptoms specific to the part(s) of the body affected. 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, 2014e).

Cutaneous Radiation Syndrome (CRS)

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 postexposure 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 occurrences 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 professionals develop about what is “normal” for their setting.

If even one patient presents with symptoms suggestive of nontherapeutic radiation exposure, aggressive investigation is warranted to discover the circumstances of the exposure. 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 clinician 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 clinician 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 a 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 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.

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.

The Occupational Safety and Health Administration (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 facility 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 (OSHA, 2005).

  • First responders are personnel who have responsibility to initially respond to emergencies. Some examples are firefighters, HAZMAT team members, law enforcement officers, lifeguards, forestry personnel, ambulance attendants, and other public service personnel. In the case of hazardous materials incidents, these personnel typically respond at the site where the incident occurred.
  • First receivers are employees at a hospital engaged in decontamination and treatment of victims who have been contaminated by a hazardous substance(s) during an emergency incident. The incident occurs at a site other than the hospital. These employees are a subset of first responders.


Two functions will occur in the triage area:

  • Actual or potential victims, who will be routed to an appropriate area to receive services, will be distinguished from those people seeking information or reassurance.
  • 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.


Those healthcare workers assigned to work in the triage area must don appropriate PPE and use Standard Precautions. These actions are based on the same guidelines used for infection prevention and control. The cornerstone of personal protection, no matter the nature of the hazard, is the correct, consistent use of PPE.

PPE for First Receivers

Personal protective equipment for the triage area includes those items listed as meeting OSHA’s Level C PPE requirements (U.S. DHHS, 2014a).

  • Protection provided: Lower level of respiratory and skin protection; adequate for radiation event response where other hazards have been determined not to be present
  • Indications: Hazards have been identified; hazards will not be absorbed by or adversely affect exposed skin; all criteria for using an air-purifying respirator are met (i.e., concentrations of all airborne contaminants are known, appropriate filters are available, oxygen levels are sufficient)
  • Who should wear: First responders and first receivers; when caring for patients/victims likely to be contaminated with radiological material
  • Equipment to be selected:
    • Full-face or half-mask, air-purifying respirators (NIOSH-approved)
    • Hooded chemical-resistant clothing (overalls; two-piece chemical-splash suit; disposable chemical-resistant overalls)
    • Coveralls
    • Gloves, outer, chemical-resistant
    • Gloves, inner, chemical-resistant
    • Boots, outer, chemical-resistant steel toe and shank
    • Boot-covers, outer, chemical-resistant (disposable)
    • Hard hat
    • Escape mask
    • Face shield
Photo of Level C PPE adequate for radiation event response

Level C–equivalent PPE. (Source: NE DHHS, 2011.)

The following considerations apply to the correct use of Level C PPE:

  • 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.
  • Open cuffs, hems, and any other potential gaps are sealed with appropriate tape. A fold-over or “courtesy” tab facilitates the removal of tape while wearing gloves.
  • A personally assigned dosimeter is worn on the outside of the primary PPE garment. The dosimeter should be placed in a position where it will not be dislodged during normal activity. A second dosimeter may be worn under the gown if facility policy dictates.

Lead aprons are not necessary. Their use can give a false sense of security and lead to disregard of evidence-based actions (U.S. DHHS, 2014b).

PPE for First Responders

Because first responders are providing care at the incident site, they may be subjected to greater levels of exposure.

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’s Level B PPE is indicated for first responders who enter radiation zones:

  • Protection provided: Highest level of respiratory protection, lower level of skin protection
  • Indications: Identified or suspected hazards requiring maximal respiratory protection; working in atmospheres containing less than 19.5% oxygen; lower-level skin hazard may be present
  • Who should wear: First responders; when entering the most heavily contaminated radiation zones to rescue victims or protect valuable property necessary for public welfare
  • Equipment to be selected:
    • Positive pressure, full face-piece, self-contained breathing apparatus (SCBA), or positive pressure supplied air respirator with escape SCBA (NIOSH-approved)
    • Hooded chemical-resistant clothing (overalls and long-sleeved jacket; coveralls; one or two-piece chemical-splash suit; disposable chemical-resistant overalls)
    • Coveralls
    • Gloves, outer, chemical-resistant
    • Gloves, inner, chemical-resistant
    • Boots, outer, chemical-resistant steel toe and shank
    • Boot-covers, outer, chemical-resistant (disposable)
    • Hard hat
    • Face shield
      (U.S. DHHS, 2014a)
Photo of Level B PPE for those entering a radiation zone

Level B–equivalent non-gas-tight encapsulating suit. (Source: U.S. DHS, 2007.)


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.

Any visible radioactive material should be handled with forceps and stored in lead or lead-lined containers. The container should be labeled with the details of the survey, including date, time, surveyor, meter used, and findings (CDC, 2014e).


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 to 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
Illustration showing a body scan to survey for radiation contamination (front view)Illustration showing a body scan to survey for radiation contamination (back view)

(Source: Radiation Emergency Assistance Center/Training Site)

Source: U.S. DHHS, 2014c.


Once the initial survey is complete, a victim’s clothing must be removed, as follows:

  • 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.


Once the victim’s clothing has been removed, a secondary survey is performed in the same manner as discussed above. Then the victim is decontaminated as follows:

  • 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.
  • Cover any wounds with waterproof dressings.
  • Transport or assist the victim to the buffer zone, where someone assigned to the buffer zone will assume responsibility for the victim.

Additional surveys and repeated decontamination may be required until surveys indicate that the radiation level is no more than twice the background radiation level or unchanged from the immediate previous reading.

Once the victim has been decontaminated, Standard Precautions and routine assessment and care pathways are indicated (CDC, 2005).

Disposal of wastewater and decontamination materials is dictated by 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.


Internal contamination is considered if high survey readings persist following decontamination. Nose or mouth contamination may indicate inhalation or ingestion.

Assessment may include analysis of urine, blood, and fecal samples or whole-body counts. Internal contamination generally does not cause early symptoms.

Radiation experts may be consulted regarding an individualized treatment plan. The following may be treatment 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.

Source: U.S. DHHS, 2014d.


Following the explosion of a dirty bomb at a crowded stadium, contaminated bystanders are transported to the local hospital emergency department (ED). 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 have undergone an instrument check, providers 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.


Treating ARS and CRS includes an interdisciplinary combination of symptom-directed interventions and ongoing assessment, as both obvious and subtle presentations are part of an evolving process.

The goals are to assess and document the patient’s ongoing status and the progression of signs and symptoms, provide life-saving and comfort-oriented care, and establish a foundation for future treatment.

Initial treatment includes, but is not limited to, the following interventions:

  • Treating vomiting immediately
  • Performing serial complete blood counts (CBCs) (emphasizing the 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 recording all clinical symptoms, particularly nausea, vomiting, diarrhea, and itching, reddening, or blistering of the skin, including time of onset
  • Taking color photographs of suspected radiation skin damage for inclusion in the patient’s record (If this is not possible, dated and timed objective descriptions that capture the extent of the injuries at the time of assessment are critical. Using a series of purpose-made human silhouettes or improvised sketches can capture the progression of cutaneous injury.)
  • Considering tissue and blood typing, as well as initiating viral prophylaxis
  • Promptly consulting with experts in radiation, hematology, and radiotherapy and radiation accident management about dosimetry, prognosis, and treatment options
  • After consultation, beginning 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

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, 2014b, e).


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 (CDC, 2007c).

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 may simply be seeking 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.

Radiation exposure fact sheets should be made available to 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, the decision to use previously identified facility staff or professionally trained over-the-phone providers of interpretation services is a complex one. Factors to consider include:

  • The existence of a contract with an interpretation provider, either as subscription service or on an as-needed basis
  • The big-picture demand (at numerous impacted sites) for the services of these interpreters, especially in a situation involving large numbers who are non-English speakers and/or large numbers of casualties
  • The skill and availability of in-house interpreters and/or bi- or multilingual staff members
  • The most efficient and effective primary use of these staff members (as care providers or as interpreters)

The use of uninjured or minimally injured family members or significant others should be a last resort. Most likely, they will be too overwhelmed by the situation to be effective communicators.

Patients who are pregnant and their families/significant others will require special counseling.

Separate areas may be needed for radiation screening and counseling for patients with minimal risk of exposure or injury.

Reporting Procedure Following a Radiation Terrorism Incident

The Radiation Emergency Assistance Center (see “Resources” at the end of this course) should be contacted to record the incident in the Radiation Accident Registry System. The facility disaster plan will indicate 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 (GS, 2011).

Initially, the organisms used are as they would be in their natural form. They have been weaponized, and because of the changes they have undergone, they will affect a broader segment of the human or animal population or crops than the naturally occurring form of the pathogen.

Dispersal of Biological Agents

While the standard chain of infection 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.
Chain of infection links in the transmission of infectious agents.

Chain of infection. In biological terrorism, the mode of transmission is intentional. (Source: Wild Iris Medical Education, Inc.)

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 is 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, but only aerosol sprays are reasonably practical. The use of small fixed-wing or rotary aircraft could be 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 departments; 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. In this context, the surveillance refers to case definitions based entirely on clinical features without any clinical or laboratory diagnosis (Jamison et al., 2006). These clinical features include:

  • Signs and symptoms of agents potentially used by biologic terrorists
  • Increases in calls or visits to emergency departments, urgent care facilities, clinics, and physicians’ offices
  • Increases in the use of over-the-counter drugs or complementary medicines used to treat potential weapon-related signs and symptoms

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 incidence 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

All the above factors reflect changes from the norm and pattern changes in the community, not the victim’s whereabouts prior to becoming ill. Thus, an 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.

An exception to the community comparison is any person with a history of recent (past two to four 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. (Note the common thread between this factor and the 2015 spread of Ebola from western Africa to Europe and the Americas.)

The relationship to symptoms presentation and travel underscores the need to include queries about travel early in the intake/triage process. 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. Today’s technology is:

  • Geared toward detecting agents in the environment so that first responders can take appropriate precautions
  • Not intended to be an aid to diagnosis
  • Complex to use and requires extensive initial and refresher training to insure the delivery of accurate information
  • Costly to purchase and maintain

Singly, any of these considerations keep widespread availability of this technology from being a practical community option. Taken in combination, they form a near-insurmountable barrier.


Several bank employees were processing recent deposits into the bank’s ATMs. One of them opened an envelope containing currency and a note stating the bills had been contaminated with anthrax. The bank manager implemented the bank’s response plan and notified public safety agencies. The workers were brought to the nearby hospital, and the hospital’s 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 the syndromic surveillance data, public health and law enforcement officials felt that no widespread exposure had occurred.

As part of the healthcare facility 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 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 in the facility were briefed, and the in-place 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 receive education and reassurance. 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.

Diseases with Potential for Use as Bioweapons

The CDC has classified more than 30 organisms as having potential for use as a biological weapon and has grouped them into three categories. 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.

Source: CDC, 2007b, 2014c.
  • First stage (10 days to 6 weeks after exposure): nonspecific flu-like symptoms, fever, dyspnea, cough, congestion, anterior chest discomfort
  • Second stage (2 to 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 to 60 seconds with soap and water or 2% chlorhexidine gluconate after spore contact (alcohol hand rubs are inactive against spores)
  • Not contagious person-to-person
Source: CDC, 2007b, 2014c.
  • 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 must be a vigorous wash for 30 to 60 seconds with soap and water or 2% chlorhexidine gluconate after spore contact (alcohol hand rubs are inactive against spores)
  • Most commonly occurring form; about 2,000 cases annually worldwide
  • Fatality: 1% if treated; ≥20% if untreated
Source: CDC, 2007b, 2014c.
  • Within 2 to 5 days 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 to 60 seconds with soap and water or 2% chlorhexidine gluconate after spore contact (alcohol hand rubs are inactive against spores)
  • Not reported in the United States


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 50 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, 2006.
  • 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; endogenous immunity can be induced by immunization with botulinum toxoid
Source: CDC, 2006.
Presentation Same 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 to 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 principal 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: CDC, 2014d.
  • 2 to 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: CDC, 2014d.
  • 1 to 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: CDC, 2014d.
  • 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 less 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, 2009, 2012).

Source: Mayo Clinic, 2014.
  • 2 to 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 to 3 days after exposure affords almost complete protection against developing disease
  • Vaccination as late as 4 to 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 to 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 for Biological Agents

The general principles of PPE for bioterrorism are based on the same Standard Precautions used to protect otherwise healthy patients from acquiring a healthcare-associated infection and in caring for patients with known or suspected benignly transmitted infections. They include hand hygiene and, depending on the anticipated exposure, the use of gloves, gowns, masks, eye protection, or face shield.

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

If contamination is from aerosolized powder or environmental exposures, PPE includes a respirator such as an N95 mask (also called an air-purifying respirator [APR]) or equivalent or a powered air-purifying respirator (PAPR).

Protective clothing is needed for decontamination of persons with powder on them.

PPE: Disposable, fit-tested air-purifying respirator

Disposable, fit-tested air-purifying respirator (APR). (Source: OSHA.)

PPE: Powered air-purifying respirator

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. Fitting and training 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.


Level A PPE is required of first responders who are at risk of direct exposure to biological or chemical hazards.

  • Protection provided: Highest level of skin, eye, respiratory protection
  • Indications: Identified or suspected hazards requiring maximal skin, eye, and respiratory protection; working in confined areas where hazards have not been fully characterized
  • Who should wear: First responders; when identified or potential risk of biological, liquid or vapor chemical hazard exposure exists
  • Equipment to be selected:
    • Positive pressure, full face-piece, self-contained breathing apparatus (SCBA), or positive pressure supplied air respirator with escape SCBA, approved by the National Institute for Occupational Safety and Health (NIOSH) (see image below)
    • Totally encapsulating chemical-protective suit
    • Coveralls
    • Long underwear
    • Gloves, outer, chemical-resistant
    • Gloves, inner, chemical-resistant
    • Boots, chemical-resistant, steel toe and shank
    • Hard hat (under suit)
    • Disposable protective suit, gloves, and boots (depending on suit construction, may be worn over totally encapsulating suit)
      (U.S. DHHS, 2014a)
Level A PPE for those at risk of direct exposure to biological or chemical hazards

Level A–equivalent totally encapsulating chemical- and vapor-protective suit. (Source: U.S. DHS, 2007.)


The first documented use of chemical weapons in declared warfare in the modern period began in World War I, and such weapons 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 under most households’ kitchen sinks or in their garages will reveal any number of potential chemical weapons. Releases of these may be overt or covert, with the same associated triage and psychosocial issues as discussed above.

Dispersal of Chemical Agents

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 an 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.

Immediate recognition of a covert chemical agent attack may be complicated by several factors:

  • Depending on the chemical agent, symptoms of exposure 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, 2003)

In addition, if a terrorist or terrorist group claims responsibility for the attack, they might provide correct or incorrect information regarding the agent used. This can further complicate initiating an appropriate response.

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

Unlike biological agents, which do not remain active in the environment for relatively long periods after delivery, chemical agents may or may not continue to be a threat after deployment. In terms of duration of potential effect and hazard target, chemical agents may be persistent or nonpersistent.

  • Persistent agents remain active for up to a month on surfaces and are most dangerous to the skin.
  • Nonpersistent agents dissipate within a few hours and are most dangerous to the lungs.

There are five major categories of chemical agents:

  • Blister
  • Choking
  • Blood
  • Nerve
  • Incapacitation/riot control


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, 2013c.
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, 2015.
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 mm Hg
Source: CDC, 2013b.
  • Clusters of acute lung or GI injury (depending on exposure); circulatory collapse; shock; tracheobronchitis, pulmonary edema, necrotizing pneumonia if inhaled
  • Inhalation: chest tightness, coughing, weakness, nausea, fever
  • Ingestion: nausea, diarrhea, vomiting, fever, abdominal pain
  • 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: EM, 2015; ATSDR, 2014a.
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)
    • Hydroxocobalamin: 5 g
  • Consult Agency for Toxic Substances and Disease Registry for specific dosing regimens (see “References” at the end of this course).
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. Care is based on the patient’s condition at time of initial evaluation.

Category and Priority Effects Clinical Signs
Source: ATSDR, 2014b.
Immediate Unconscious, talking but not walking, or moderate to severe effects in two or more systems (e.g., respiratory, GI, muscular, CNS) Seizing or postictal, severe respiratory distress or apneic, recent cardiac arrest
Delayed Recovering from agent exposure or antidote Diminished secretions, improving respiration
Minimal Walking and talking Miosis, rhinorrhea, mild to moderate dyspnea
Expectant Unconscious Cardiac/respiratory arrest of long duration
Source: ATSDR, 2014b.
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
  • Antidotes: Atropine and pralidoxime chloride (2-PAM Cl). Atropine administered every 5 to 10 minutes until secretions begin to dry up; 2-PAM Cl administered within minutes to a few hours (depending on the agent) following exposure to be effective, generally no benefit in giving more than three injections of 2-PAM Cl.
  • Military Mark I kit containing autoinjectors provides the best way to administer the antidotes to healthy adults; one autoinjector delivers 2 mg atropine and the other delivers 600 mg 2-PAM Cl.
  • If Mark I kit is unavailable or the patient/victim is not an otherwise healthy adult, consult Agency for Toxic Substances and Disease Registry for specific dosing regimens (see “References” at the end of this course).

A woman walked into a 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 35 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 theater employees, who found a note on the locked door calling the 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 40 or more victims. Shortfalls to provide this care were readily apparent. While atropine and diazepam were readily available in the first response vehicle and from their base station in adequate quantities to treat the number of victims, the necessary 2-PAM 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 require ventilatory support.

The community EOC was contacted. 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 2-PAM 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 nonlethal 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, 2013a; Medscape, 2013a; Medscape, 2010b.
  • 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 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 for Chemical Agents

The following PPE guidelines apply when all of these conditions have been met:

  • The receiving facility is not the release site.
  • The identity of the substance is unknown.
  • 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 PAPR or a combination 99.97% high-efficiency particulate air (HEPA) / organic vapor / acid gas respirator cartridges (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.

A higher level of PPE is required of first responders who are at risk of direct exposure to chemical hazards (see “OSHA Level A PPE for First Responders” earlier in this course).


Well-thought-out disaster plans 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 terrorist act. While no plan can anticipate and spell out responses to every situation, enough consideration is needed 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, healthcare professionals must do everything possible to ensure that their personal responsibilities have already been met. This is not to imply that concern for loved ones will vanish simply because one has a household disaster plan in place. Instead, the knowledge that one has done as much as possible to prepare should assist caregivers 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. For example, standardized, nationwide classes offered by the American Red Cross and the Community Emergency Response Team (CERT) program are a great starting point for preparing one’s own household and also may be a doorway into community involvement (see “Resources” at the end of this course).

Even if one never needs to implement a household disaster plan because of a terrorist incident, having such a plan may also prove useful in the more likely scenario of a natural disaster. General disaster preparedness translates directly to being ready for a terrorist incident, and vice versa.

  • An individual or household located outside of one’s immediate area should be chosen to serve as a household emergency contact to “check in” with in times of emergency, including a terrorist attack. This is the single identified person or household to be contacted.
  • An emergency contact should not be located in the same immediate physical area. In case of a disaster, their focus will be on their own well-being, and they most likely will be unable to realistically accept the additional responsibility of serving as someone else’s household’s contact.
  • The contact should have both the maturity and availability to accept this responsibility.
  • The contact should agree ahead of time to serve in this role.
  • Everyone in the household should know how to reach the contact.
  • One may offer to reciprocate for the contact person.

Professional Preparedness

In the case of a terrorist attack, it is likely that healthcare professionals will be at work beyond their normal shifts due to increased patient load. If the nature of the attack calls for quarantine or lock down, employees may not be able to leave the facility, nor will replacements be allowed to report for work. Any emergency survival kit located in a vehicle may not be accessible, nor is it likely that anyone will be able to bring a “care package” from home, at least in the initial hours. Thus, it is important to keep a personalized “survival kit” in a secure location at the workplace.

  • Contact lens case and solution and current prescription glasses
  • Eye lubricant drops
  • Batteries for hearing aid, if needed
  • Several days’ supply of any required or anticipated medication
  • Extra socks and underwear
  • Personal care products (deodorant, shampoo, oral hygiene)
  • 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
  • A small supply of nonperishable, ready-to-eat food items in case of individual needs or as personal “comfort food”

The following are some additional considerations for creating one’s personal kit:

  • Think “outside the box,” that is, beyond what is needed for a normal shift.
  • Ask, “What would keep me from being effective if I didn’t have it?”
  • Regularly replace items with an expiration or “use by” date.

Healthcare professionals should read and understand their facility’s disaster preparedness plan according to their position and responsibilities at the facility. It is recommended that individual employees:

  • Focus on the section of the facility disaster plan that most closely spells out the role their unit or department would play in treating victims of terrorism.
  • Concentrate on understanding one’s individual role in the event victims of a terrorist act were to present at the facility. Consider periodically running a “mental disaster drill.”
  • Ask questions if there is something that is ambiguous or unclear.
  • If something appears to be absent, use the chain of command to move any concern forward.
  • Be tactful and mission-focused in articulating observations.
  • Consider offering to assist with revising or updating the plan. Be part of the solution, not a “finger pointer.”
  • Participate actively in unit or facility safety drills and in debriefings afterwards.
  • Ensure one’s contact information is current on alert rosters or telephone trees.

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 terrorist 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 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. Facilities and individuals may need to mentally substitute the appropriate workplace designation that best describes their setting and consider what adaptations their facility would need to make.


The most practical way to develop or review the plan is to gather both individuals who will develop polices and those who will be responsible for implementing them and then 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.

The more comments and most varied input—asking “What other things does our facility need to consider?”—can 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
  • How they would coordinate activities with other emergency response agencies and facilities within the community
  • An expanded concept of “community,” to plan for requesting and providing mutual assistance to other healthcare facilities and emergency response providers

One very basic way to model how a 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 or heard about a recent visit from a government or accreditation survey team. In this instance, discharge may be defined 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 preparedness plan. The group includes direct-care providers as well as middle and senior managers. Prior to the first general meeting, each group member 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 expanded outpatient surgery center the previous summer. The nursing team identifies the following facts:

  • Approximately 5,000 cases per year are done in these ORs (operating rooms). Since each patient must be accompanied by a responsible adult, this means that about 10,000 individuals access the facility annually.
  • The outpatient surgery center often uses borrowed equipment and just-in-time-delivered specialty equipment and implants. This brings product representatives into the center several times each week. Product representatives also come to the center to provide in-service education and intraoperative guidance to surgical teams. Because many of these industry personnel have long-standing relationships with the surgery center staff, their presence in any part of the surgery center is no longer questioned.
  • There are now additional doors for patients and staff, a small loading dock, and two corridors connecting to the main building.
  • Some facility staff and physicians have developed the habit of using the connecting corridors as a shortcut to the parking structure.
  • Prior to the opening of the surgery center, there was a community open house and extensive media coverage.
  • In addition, every year Perioperative Nurse Week is observed with self-guided tours of the entire outpatient surgery center for the public.

The nursing 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 of the preoperative area, one specific OR, and the PACU (postanesthesia care unit).
  • They recommend that all product representatives be required to sign in with facility security and wear visible visitor badges in addition to company nametags.
  • Lastly, they stress the need to curtail unrestricted access to the entire outpatient surgery center.
Regular Plan Review

Activation of the disaster preparedness 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. It is important to consider things like the date of the last full or partial revision, currency of contact rosters, and changes in organizational structure that would have an impact on the plan.

  • Does the facility either have 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 a facility will allow access to those presenting for care while simultaneously protecting 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. Healthcare facilities also need a method to control access if situations suggest that an unruly crowd will force its way into the building.

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
  • Prevent other staff from becoming exposed
  • Protect equipment
  • Ensure contaminated victims do not bypass the decontamination area or enter the ED without passing inspection

Consider how many access points exist in the 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 the perimeter.

  • How many checkpoint personnel will be needed to monitor these points?
  • Does the facility have an adequate number of security staff, or will other workers need to be designated and trained to augment them?
  • Which areas require a fully trained security staff member and which can 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.

The need for immediate, life-saving treatment supersedes decontamination.

  • Are emergency treatment supplies needed for this area packaged so 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? (Once items such as medications and most supplies enter this area, they are lost to the system.)

The facility should 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 be conducted 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 nonambulatory) 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 Postdecontamination 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 be 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. In 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 PPE needed to function as a first-receivers were not stockpiled at the facility, the facility would need to obtain it from a source in the community.


On the positive side, 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 is put into action by the power of altruistic energy.

Adrenalin will carry responders through the immediate period following the event. However, the body and mind are not designed to sustain this level of stimulation for a prolonged period. When an individual’s threshold has been reached (which will vary from person to person and change over time for a given person), the effects of sustained enhanced alertness will begin to manifest themselves.

Once the initial response to the event is over and the euphoria of having “made a difference” has faded, the delayed effects of hypervigilance and prolonged labor in difficult circumstances will result as stress. There are both physical and psychological manifestations of responding to stressful situations.

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 (PsychologistWorld, 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 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.

In their 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, a 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, 2011). 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. If the person reacts to this GI upset 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 require less and less to trigger them.

Among the common presentations of vicarious trauma are the following:

  • Irritability and outright anger are common early signs, as is denial.
  • Blaming may be directed inward, outward at specific individuals or institutions, or more globally.
  • 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 when their acuity is most needed.
  • At a time when support given to and received from one’s personal and professional circles are of paramount importance, issues with interpersonal and/or professional relationships may suffer, as the caregiver becomes increasingly inward 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 often used interchangeably with the terms compassion fatigue and vicarious trauma, the term burnout describes 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).

Source: Sabo, 2011.
General Causes
Lack of opportunity to refuel and regenerate between caregiving situations Repetitive exposure to others’ traumatic experiences Low job satisfaction; feelings of being powerless and overwhelmed
Unique Triggers
Extreme other-directed attitude Immersion in helping traumatized victims Workplace environment
Characteristic Signs
Detachment and decreased intimacy; somatic complaints Somatic complaints; intrusive imagery Negativity (outwardly and inwardly directed)
Negative Effect on Worldview
Yes Yes No
Loss of Ability to Feel Compassion
Yes Possible No

Minimizing a Negative Response to Stress

The following steps are helpful in identifying and responding effectively to one’s stress triggers:

Know your 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 inevitable setbacks as a learning opportunity and a chance to begin anew.

Go back to the basics.

  • Strive for an adequate intake of nutritious food.
  • Use comfort foods as treats, not essential components of a meal plan.
  • Ensure an adequate, balanced 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, if physical separation is not possible.
  • 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 where you are going. Ask him or her to wake you if your internal alarm clock is fallible. Consider saving your battery charge for actual calls, not using alarm apps.

In the event of a terrorist attack, it is important to be realistic in assessing one’s own reactions and those of 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 coworkers.

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 everyone has been affected as a person and as a professional. All participants in the response need to take advantage of resources available in the workplace and community to help move forward from what they have experienced and how they have been impacted.


The CDC’s Health Alert Network (HAN) is a national program providing information about urgent public health incidents with public information officers; federal, state, territorial, and local public health practitioners; clinicians; and public health laboratories. HAN collaborates with its partners to develop protocols and stakeholder relationships to ensure a robust platform for the rapid distribution of public health information (CDC, 2015b).

Individuals can sign up on the CDC website to receive HAN E-mail Update alerts. (See “Resources” at the end of this course.)

HAN Message Types

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: provides vital, time-sensitive information for a specific incident or situation; warrants immediate action or attention by health officials, laboratorians, clinicians, and members of the public; and conveys the highest level of importance
  • Health Advisory: provides important information for a specific incident or situation; contains recommendations or actionable items to be performed by public health officials, laboratorians, and/or clinicians; may not require immediate action
  • Health Update: provides updated information regarding an incident or situation; unlikely to require immediate action
  • Info Service: provides general public health information; unlikely to require immediate action
    (CDC, 2015b)


The prospect of another terrorist act within the United States may be terrifying, but one may occur. The result of any terrorist attack is the creation of casualties, and this makes it a healthcare as well as a public safety concern.

Viewed from this perspective, both healthcare facilities and the personnel who staff them have a professional responsibility to prepare to care for the victims who will present to them. Acquiring and maintaining the information and skills needed to effectively respond to the casualties of such an action are necessary initial steps to be ready for those patients.


NOTE: Complete URLs for references retrieved from online sources are provided in the PDF of this course (view/download PDF from the menu at the top of this page).

Agency for Toxic Substances and Disease Registry (ATSDR). (2014a). Medical management guidelines for hydrogen cyanide. Retrieved from

Agency for Toxic Substances and Disease Registry (ATSDR). (2014b). Medical management guidelines for nerve agents. Retrieved from

Centers for Disease Control and Prevention (CDC). (2015a). Medical countermeasures for radiation exposure and contamination. Retrieved from

Centers for Disease Control and Prevention (CDC). (2015b). Health alert network (HAN). Retrieved from

Centers for Disease Control and Prevention (CDC). (2014a). Acute radiation syndrome (ARS): a fact sheet for the public. Retrieved from

Centers for Disease Control and Prevention (CDC). (2014b). Cutaneous radiation injury. Retrieved from

Centers for Disease Control and Prevention (CDC). (2014c). Centers for Disease Control and Prevention expert panel meetings on prevention and treatment of anthrax in adults. Retrieved from

Centers for Disease Control and Prevention (CDC). (2014d). Plague: resources for clinicians. Retrieved from

Centers for Disease Control and Prevention (CDC). (2014e). Acute radiation syndrome (ARS): a fact sheet for clinicians. Retrieved from

Centers for Disease Control and Prevention (CDC). (2014f). Measuring radiation. Retrieved from

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