Repeating the same drills and training scenarios can become stale. Sometimes it takes aliens, zombies, or vampires to shake things up. That’s where counterfactual simulation comes in.
Business author Josh Kaufman describes counterfactual simulation as “applied imagination.” It’s done by coming up with an outlandish scenario or an intractable problem, planning for it, and applying the results to the real world. It’s a “what if?” exercise where you imagine something to be true, and your mind fills in the gaps between here and there. It has been used to develop many large-scale government plans and responses to actual incidents.
An example of this would be planning for an alien invasion of the United States (a simulation that’s actually been run). The real-world application of this simulation would end up producing a master plan for defending the United States against a numerically and technologically superior force. Similar exercises—using outlandish scenarios to encourage out-of-the-box thinking—may be useful for EMS. Over the next few columns, we’ll consider a few examples.
The inspiration for this month’s column is 28 Days Later, a movie featuring a zombie apocalypse following a viral outbreak at a medical research laboratory. The virus featured in the movie is the Rage virus, a mutated strain of Ebola that causes constant uncontrollable anger. The infected behave as if they have something similar to the rabies virus. Like most real-life viruses, Rage inspires its carriers to pass on the virus, thus ensuring its survival. Unfortunately, in the passing, most victims are killed. I use this movie in my “Surviving a Zombie Apocalypse” lecture as an example of something—a new virus impacting patient behavior—EMS providers could legitimately one day face.
The EMS Response
Like any other disaster that’s completely unknown when the calls start coming in, EMS will initially be responding to individual incidents for things that seem rather normal. Dispatch will likely receive a number of calls regarding assaults, fights, fires, and motor vehicle accidents. This will start slowly but rapidly start approaching a crescendo that cannot be managed effectively.
Initially responding crews will be overwhelmed quickly because they will be unsuited to handle those infected by the Rage virus. Police officers will begin firing on their attackers until they run out of ammunition or are overwhelmed by the numbers of affected. Some EMS providers will be attacked immediately by patients. They will then become infected and attack their own colleagues and anyone else around. EMS providers, with no offensive weapons available to them and relatively few items to use as makeshift defensive weapons, will attempt to retreat to their ambulances, where they will be overrun.
The Rage virus is spread by infecting someone with body fluids—any bodily fluids. Like many other diseases we deal with in real life, this infection can occur from a bite, scratch, or any intrusion into the mucous membranes or an open wound. It only takes a miniscule amount to cause full infection. There isn’t enough time for any treatment or prophylactic. Because of the highly infectious nature of the disease and its routes of transmission, it will be difficult to both avoid infection and fight back at the same time.
Unfortunately, a typical EMS response here will result in the death of almost everyone on duty. Any surviving providers will be nothing more than individuals aligning themselves with other survivors and attempting to hide out and stay alive. Soon after an event like this, all government functions will shut down. In the movie Great Britain was given up and quarantined from the rest of the world 15 days after the release of the Rage virus.
On the local level there would be very little atypical EMS response available. In a scenario like this, there are two basic options: Keep responding or stop responses altogether until conditions change. Both of these choices would result in mass deaths. Providers who stay in their stations and do not respond would eventually be found by the infected and overrun. Rural providers will survive longer in isolated stations. Much will depend on how soon authorities realize what is happening and change tactics.
Lessons to Implement
Is it likely that, at some point in our lifetimes, a virus could escape a lab and create havoc on a mass scale like this? Absolutely—it almost happened in Reston, Va., in 1989, only miles from Washington, D.C. Between 2004 and 2015 the U.S. Army inadvertently shipped 575 live anthrax samples to facilities all over the globe. Similar events have probably happened many times on a smaller and less publicized scale.
It’s not always possible to recognize a major event when it first begins. A great many people, including providers, may die before it is known what’s happening. How likely are dispatch and supervisors to recognize patterns of calls and piece together an event, especially if the calls seem crazy? More than likely individual providers will piece it together first and disobey orders. In your system, how much autonomy would the on-scene provider have versus a supervisor or other person higher in the chain of command?
How safe are your stations? If allowed by budget, modern EMS stations should be at least minimally hardened and fortified and able to be shut down and used as an emergency shelter for the crews and other public safety personnel if needed. This isn’t an outlandish idea. The newer stations where I live in coastal South Carolina are hardened and fortified to withstand hurricanes and allow crews to shelter in place.
Along with the stronger structure, keep a supply of food, water, and other necessary supplies in the station as part of standard practice. The station should also be capable of running on its own power with a generator and/or solar panels.
Sadly, you won’t see this in many stations. In my time in EMS, I have worked out of stations situated in mobile homes, private homes, storefronts, garages, and a library. I even worked one truck that had no station. We picked up our ambulance at headquarters each shift and either roamed or sat in parking lots the entire time.
Examine these ideas in your own service. Is there freedom in the power structure to make independent decisions or disobey orders when necessary? If your crew needed to shelter in place for an event, would your station be adequate? How long?
In addition to other ideas, the notion of arming providers comes up quite often. Should providers have access to weapons while on duty, either personal ones or provided by the employer? We know there are a number of things on an ambulance that can be used as a weapon, but that’s not quite the same. Although it was prohibited by my service, I always carried a collapsible baton in my cargo pocket. I also carried a pocketknife that was large enough to use as a weapon if necessary. I had the great fortune of being trained with these weapons and close-quarters combat in the military. Even so, there were times when I scanned a room for something to use in case a call went bad.
It might be controversial, but it is my opinion that providers should be supplied with something of a defensive nature and trained to use it to defend themselves or a patient. A collapsible baton is an adequate choice for such a device. Aside from how to use it, a necessary part of the training would also be in knowing when to deploy it and when not to.
I would love to hear your thoughts on other atypical response ideas, especially if you work somewhere such things are already in place.
Send me an e-mail and let me know how you would make out. Reach me at firstname.lastname@example.org. Use the subject line 28 Days Later Medic.
Upcoming columns will examine more scenarios that will likely never happen but can help responders who think them through prepare for anything that might be encountered in EMS.
David Powers, ThD, BCETS, BCECR, is a decorated veteran of the U.S. Marine Corps and U.S. Army and a founding member of the Department of Homeland Security, where he participated in disaster planning and helped war-game scenarios and responses. He is a popular speaker at public safety conferences and for various government agencies. Contact him at redteamgoals.com.