Under Attack! Protecting EMS Personnel

On May 26, 2004, Attorney General John Ashcroft and FBI Director Robert Mueller warned that credible intelligence from multiple sources indicates that al-Qaeda plans to attempt an attack on the United States in the next few months. While the focus was on upcoming major events like the political conventions, they also stated that law enforcement was concerned that terrorists could target so-called soft targets in the United States, such as shopping malls, hotels and transportation hubs. Given this current reality, EMS responders, whether in a metropolitan area or a small town, need to be prepared for such an event.

The first element of preparation is to understand the nature of the threat that you are facing. EMS personnel arriving at an attack site must be protected so they can deliver treatment to victims and not become a casualty of the event. This means they must have adequate training in the use of and access to personal protective equipment (PPE). EMS responders should also be aware of their surroundings in the event a secondary attack occurs after their arrival. For example, a car bomb explosion may be a cover for a subsequent secondary release of a biological agent. In Israel, EMS and police personnel arriving at a scene have routinely become targets for secondary events by terrorists. That same scenario could become reality in our country as well.2

Nature of an Attack

The level of PPE required will be determined by the nature and severity of the attack and the level of threat each situation presents. EMS personnel need to understand what agents might be used, how they could be delivered and what the potential targets are in their area. When a biological or chemical attack occurs, it may not be readily apparent what agent has been used.

In a chemical attack with a high dose of agent, people will immediately show signs such as choking, respiratory failure, burning eyes and skin, etc. This situation calls for using the highest level of personal containment for the EMS responder.2 This includes a fully encapsulated suit and self-contained air system as described in Table I, Level A.

However, at lower concentrations, some agents like phosgene or the blister agent mustard gas may not show toxic effects for 2¡V6 hours after exposure. Exposed individuals may leave a scene, then go to a hospital or clinic hours later showing signs of exposure.

In a biological incident, the primary attack may be an overt event where individuals witness an agent being released by a spraying device, such as a truck equipped with an agricultural sprayer, a small airplane or a simple canister spraying device. However, a terrorist attack will most likely be a covert event where an agent is released into the ventilation system of a building, in a subway station or inside a sporting event. Here, a smaller, more manageable amount of agent can be released without detection. In a known attack situation, first responders will probably not know initially what agent has been released. In this situation, it is best to assume a ¡§worst case¡¨ scenario and use the highest level of personal containment, Level A, which requires a fully encapsulated suit and self-contained breathing apparatus (SCBA).4 Since the incubation period for most biological agents ranges from 2¡V20 days in a covert attack, the site will remain unknown until clusters of victims all exhibiting the same symptoms begin to show up at hospitals. Identifying common activities and geographic locations of these individuals over the past few days will allow the exposure to be traced back to a specific location;5 however, it is important to realize that people may have left the exposure site and traveled to a wide variety of locations. Thus, it is important for medical and EMS staff to be in contact with their counterparts in nearby cities and towns to try to identify other foci of similar illness in individuals who might then be traced back to the same site (i.e., a basketball game or mall). With the passage of time, most biological agents will eventually deteriorate in the environment and be largely rendered inactive by the time the site is identified. The rate of deterioration is dependent on weather conditions (how hot or wet it has been), whether an attack was inside or outside, and the method for preparation of the agent. For example, freeze-dried bacteria or spores will persist for longer periods of time in dry conditions. Some organisms like Brucella suis, one of the species causing brucellosis, are stable for long periods of time in wet ground or on food.6