Chapter 50Terrorism Injured Patients
Unit Summary
This chapter describes how you can prepare to respond to events relating to terrorism by discussing types of terrorist events and patient management. You will also learn the signs, symptoms, and treatment of patients who have been exposed to chemical, biologic, radiologic, nuclear, and explosive (CBRNE) agents or injured by a suicide bomb and explosive attacks. Lastly, issues of responder health and safety at the scene of a terrorist attack will be discussed in detail.
National EMS Education Standard Competencies
EMS Operations
Knowledge of operational roles and responsibilities to ensure patient, public, and personnel safety.
Mass-Casualty Incidents Due to Terrorism and Disaster
• Risks and responsibilities of operating on the scene of a natural orman-made disaster. (pp 2289-2311)
Knowledge Objectives
- List key questions to consider when responding to a terrorist event.(pp 2289-2290)
- Define international and domestic terrorism. (pp 2290-2291)
- Define and specify types of terrorist groups. (pp 2291-2293)
- List various examples of terrorist agendas. (pp 2291-2293)
- Discuss the color-coded advisory system’s replacement with the NationalTerrorism Advisory System (NTAS). (pp 2293-2294)
- Discuss what actions paramedics should take during the course of theirwork to heighten their ability to respond to and survive a terroristattack. (pp 2293-2297)
- List various examples of potential terrorist targets. (pp 2293-2294)
- Discuss factors to consider when responding to a potential weapon ofmass destruction incident, including preincident indicators, the type oflocation, the type of call, the number of patients, and victims’ statements.(pp 2293-2297)
- Discuss key response actions to take at the scene of a terrorist event,including establishing scene safety, ensuring personal protection, notification procedures, requests for resources, and establishing orworking within command. (pp 2294-2297)
- Define secondary device, and discuss the importance of continuallyreassessing scene safety. (p 2297)
- List the four main categories of weapons of mass destruction. (p 2297)
- Discuss specific types of devices used by terrorists, including explosives,ammonium nitrate, and suicide bombers. (pp 2297-2298)
- Define terms related to chemical agents, including persistency, volatility,contact hazard, and vapor hazard. (p 2298)
- Describe specific vesicant agents. (pp 2298-2299)
- Discuss signs, symptoms, and treatment for vesicant exposure.(pp 2298-2299)
- Describe specific pulmonary agents. (pp 2299-2300)
- Discuss signs, symptoms, and treatment for exposure to a pulmonaryagent. (pp 2299-2300)
- Describe specific nerve agents. (pp 2300-2302)
- Discuss signs, symptoms, and treatment for exposure to a nerve agent.(pp 2300-2302)
- Describe specific industrial chemicals and insecticides. (pp 2302-2303)
- Discuss signs, symptoms, and treatment for exposure to a cyanideagent. (pp 2302-2303)
- Define terms related to biologic agents, including dissemination, diseasevector, communicability, and incubation. (p 2303)
- Describe signs, symptoms, and treatment for smallpox. (pp 2304-2305)
- Describe signs, symptoms, and treatment for viral hemorrhagicfevers. (pp 2304-2306)
- Describe signs, symptoms, and treatment for inhalation and cutaneousanthrax. (p 2306)
- Describe signs, symptoms, and treatment for plague. (pp 2306-2307)
- Describe signs, symptoms, and treatment for exposure to botulinumtoxin. (p 2307)
- Describe signs, symptoms, and treatment for exposure to ricin.(pp 2307-2308)
- Define syndromic surveillance, and discuss its importance during apotential terrorist event. (p 2308)
- Define radiation, and describe the difference between alpha, beta, gamma,and neutron radiation. (pp 2309-2310)
- Describe what a radiologic dispersal device, or dirty bomb, is and how it isused for terrorism. (p 2310)
- List protective measures to take when responding to a radiologicevent. (p 2311)
- Discuss medical management of a patient who was potentially exposed toradiation. (p 2311)
Skills Objectives
- Demonstrate how to use a nerve agent antidote kit. (p 2302)
Readings and Preparation
Review all instructional materials including Chapter 50 ofNancy Caroline’s Emergency Care in the Streets, Seventh Edition, and all related presentation support materials.
Support Materials
•Lecture PowerPoint presentation
• Case Study PowerPoint presentation
Enhancements
•Direct students to visit the companion website to Nancy Caroline’s Emergency Care in the Streets, Seventh Edition, at for online activities.
Cultural considerations Terrorism can be a very sensitive topic for some ethnic cultures as well as adherents of differing types of religions and beliefs. Discussions that turn into accusations have no place in learning.
Teaching Tips
As mentioned in the cultural considerations section above, a discussion of terrorism can easily become a discussion on culture, ethnicity, and religious beliefs, which some may find offensive. It is very important to discuss the “act of terrorism” rather than picking a culture and/or belief that may have perpetuated it.
Unit Activities
Writing activities: Asign students one of the five exposure methods: chemical, biologic, radiologic, nuclear, and explosive (CBRNE). Students are to discuss the types of agents that may be used and what effects would be seen in patient care.
Student presentations: Have students present the results of their written report or group activity.
Group activities: Divide students into groups. Have each group determine potential terrorist targets within your local area as well as county/statewide. Discussion should include why each group made their selections.
Visual thinking: Have students identify some of the signs and symptoms that may be present when dealing with an exposure to a terrorist event. This can be accomplished using pictures from the chapter or those that can be found on the internet.
Pre-Lecture
You are the Medic
“You are the Medic” is a progressive case study that encourages critical-thinking skills.
Instructor Directions
Direct students to read the “You are the Medic” scenario found throughout Chapter 50.
•You may wish to assign students to a partner or a group. Direct them to review the discussion questions at the end of the scenario and prepare a response to each question. Facilitate a class dialogue centered on the discussion questions and the Patient Care Report.
•You may also use this as an individual activity and ask students to turn in their comments on a separate piece of paper.
Lecture
I. Introduction
A.Terrorist attacks have sharply increased over the last decade, happening several times a week around the world.
1.International and domestic terrorist groups have increased their targeting of civilian populations.
2.You should be prepared mentally and physically for the possibility of an attack.
B.Terrorism threatens the health and safety of paramedic responders.
1.During the sarin attacks in Tokyo in 1996, 10% of the paramedics responding were sickened because they didn’t wear the proper personal protective equipment (PPE).
2.The September 11, 2001, attacks brought health and safety to the forefront.
a.450 emergency responders, 15% of the total victims, were killed that day.
b.Many more paramedics and EMTs were injured, developed chronic disorders, or experienced depression and physiologic problems.
3.EMS providers are encouraged to seek additional training and participate in drills to develop the skills needed to respond to a terrorist event.
II. Terrorism
A.Terrorism is defined by the US Department of Justice as a violent act dangerous to human life, in violation of the criminal laws of the United States or any state or subdivision thereof, to intimidate or coerce a government, the civilian population, or any segment thereof, in furtherance of political or social objectives.
1.Mass destruction, assassinations, and kidnappings with the purpose to influence or affect a government are also defined as terrorism.
2.Terrorism is often used as a form of asymmetric warfare.
a.Groups wage war against populations with unconventional weapons and covert tactics that are unequal to military resources or capabilities.
3.Terrorists tend not to discriminate when selecting their targets and have intentionally attacked children.
a.In 2004, 30 heavily armed terrorists and suicide bombers took over a school in Beslan, Russia, holding children hostages over 3 days.
i.334 hostages were killed, many children.
b.In 2011, a lone terrorist exploded a car bomb in Oslo and then opened fire at a summer camp, killing 69 people.
B.International terrorism
1.International terrorism (cross-border terrorism): Acts of terror committed by foreign agents
2.Categorized into subgroups:
a.Non-state-supported terrorism
i.Terrorism that is either indigenous or transnational
ii.Doesn’t receive direction or support from a government
b.State-sponsored terrorism
i.Funded or supported by a government
ii.Government holds close ties with the group, but the group still acts independently.
c.State-directed terrorism
i.Terrorists act as direct agents of the government.
C.Domestic terrorism
1.Domestic terrorism: Perpetrators are citizens of the country that is being attacked.
2.Examples of domestic terrorism:
a.The Centennial Olympic Park bombing in Atlanta during the 1996 Summer Olympics.
i.Over 100 people were injured and 2 people were killed.
b.The destruction of the Alfred P. Murrah Federal Building in Oklahoma City in 1995
i.168 people were killed, including 19 children.
c.Post-9/11 attacks in the United Kingdom and plots in the United States:
i.The thwarted 2006 Sears Tower plot
ii.The thwarted 2006 Toledo, Ohio, terror plot
iii.2007 Fort Dix, New Jersey, attack plot
iv.2008 bombing of Armed Forces recruiting office in Times Square
v.2009 Fort Hood, Texas, shooting that killed 13 people and wounded 30
vi.2009 Little Rock, Arkansas, Armed Forces recruiting office shooting that killed one recruiter and injured a second
vii.The thwarted 2009 New York subway and United Kingdom plots
viii.The failed 2010 Times Square car bombing
ix.2010 Austin, Texas, IRS office attack that killed one worked and the suicide attacker who flew his plane into the building
x.The failed 2010 Portland, Oregon, car bomb plot
xi.2011 mail bombing of two Maryland government buildings
D.Types of terrorist organizations
1.Terrorist organizations can be defined as one or more of these:
a.Violent religious groups/doomsday cults
i.Often seek apocalyptic violence or mass murder
ii.Believe in eradicating or cleansing a region (or Earth) of people who don’t practice their faith
b.Extremist political/social groups
i.Violent separatist groups who are looking for political, economic, or social freedom
ii.May seek to kill or evict foreigners, migrants, or people with different ethnic, racial, sociologic, and/or cultural backgrounds
iii.Use terror to influence economic or immigration politics and the drawing and redrawing of geopolitical borders
c.Technology or “cyber” terrorists
i.Attack technologic infrastructure using technology to draw attention to their cause
ii.It is common for them to “hack” into computer systems and introduce corruptive computer programs.
iii.They can extract information, but they can also cause harm to the computers and the machines or processes they control (security systems).
iv.It is hard to detect and shut down these attacks early, if at all.
v.These terrorists tend to work in groups.
d.Single-issue terrorist groups
i.These groups include anti-abortion, animal rights, anarchists, and eco-terrorists.
ii.They threaten or use violence as a way to advance their views and goals.
iii.These groups usually represent the violent side of a non-violent group that wants to effect change through legal and socially acceptable means.
(a)Look for immediate and effective response to their demands when the nonviolent methods are seen as ineffective
e.Narcoterrorists
i.Uses terror to take control of a region, its politics, or government with a goal of manufacturing, distributing, and selling drugs without prosecution
ii.Often target military, police, anti-drug politicians, government officials, and innocent civilians in order to gain control from local authorities
iii.The revenue of the drugs makes the groups more heavily armed, organized, and funded than the local authorities.
f.Other subcategories include:
i.Hate groups
ii.Patriot groups
iii.Militia groups
iv.Common-law groups
v.Cult groups
vi.Single-issue groups
vii.Lone wolves
2.Some terrorist groups may have similar traits to several of these categories or join forces with other groups that use different methods but have the same goal or target.
3.Al Qaeda is the most infamous international terrorist organization.
a.Their influence and membership has spread across the Middle East over the last two decades.
b.They are known for their violent, simultaneous, coordinated attacks.
i.This is in place to confuse, spread thin, and overwhelm emergency response to the incidents.
c.They exhibit trends toward apocalyptic violence to affect a combination of political, geopolitical, and religious goals.
4.Terrorist groups thrive in regions with weak or corrupt regional governments.
a.Many groups establish training camps and operation bases in remote, austere locations.
5.Most attacks require multiple terrorists or “actors” that work together.
a.These people are recruited, trained, financed, and provided with equipment and intelligence.
III. Paramedic Response to Terrorism
A.Recognizing a terrorist event (indicators)
1.Acts of terror are usually covert, and the public safety community typically has no prior knowledge of where, when, or the nature of the attack.
2.It is important that you can recognize risks and high-value targets within your jurisdiction.
3.Some potential high-value targets for terrorists include:
a.Military bases/installations and military recruiting centers
b.Rail and metro transport systems
c.Large bus depots
d.Airports/seaports
e.Chemical plants/chemical transfer stations or chemical transportation
f.Petrochemical storage or transportation
g.Dams and reservoirs
h.Bio labs
i.All large gathering spaces/places
i.Stadiums
ii.Sporting arenas
iii.Parade routes
j.Government buildings
i.Court houses
ii.Federal buildings
iii.Public safety headquarters
k.Hospitals
l.Large religious venues
i.Church
ii.Mosque
iii.Temple
iv.Synagogue
m.Large shopping centers and malls
n.Large demonstrations or rallies
o.Large financial centers
i.Financial markets or exchanges
p.National symbols
i.Monuments
ii.Memorials
4.The National Advisory System (NTAS) has replaced the color-coded Homeland Security Advisory System which was instituted in 2002.
a.NTAS alerts apply to the United States and its territories.
b.It alerts responders to the potential for an attack and specifics about the threat.
i.Who will be potentially affected
ii.Geographic area
iii.Transportation concerns
iv.The nature of the threat
c.Alerts will include steps that people or communities can take to protect themselves.
d.The alert will specify if the threat is:
i.Elevated, meaning there is not specific information about the timing or location
ii.Imminent, meaning the threat is believed to be impending or expected to occur soon
e.Alerts are posted at DHS.gov/alerts and distributed through social media.
f.The DHS has not issued specific recommendations for EMS personnel to follow in response to the alert system.
i.You should know the threat level everyday, and take precautions throughout normal daily duties.
5.While on duty you must make appropriate decisions regarding the potential threat of terrorism, observing:
a.Preincident indicators
i.Has the NTAS posted a threat warning?
ii.Has violent political activism increased recently?
iii.Are you aware of any credible threats made against the location, gathering, or occasion?
b.Type of location
i.Is the location a monument, infrastructure, government building, or specific location like a temple?
ii.Is there a large gathering like a parade or political demonstration?
iii.Is there a special event like a college football game?
c.Type of call
i.Is there a report of explosion or suspicious device nearby?
ii.Does the call come in as someone having unexplained coughing and difficulty breathing?
iii.Are there reports of people fleeing the scene?
d.Number of patients
i.The most important clue is if there multiple patients with similar signs and symptoms.
e.Victims’ statements
i.The second best indicator is if people fleeing the scene are giving statements like:
(a)“Everyone is passing out.”
(b)“There was a loud explosion.”
(c)“There are a lot of people shaking on the ground.”
B.Response actions
1.When you suspect that there is a terrorist act or a WMD has been used take these actions to ensure your safety and put yourself in the position to help the community:
a.Ensure scene safety and personal safety.
b.Notify your dispatch and/or supervisor of the incident.
c.Request additional specialized resources.
d.Establish command.
e.Initiate multiple-casualty incident procedures.
2.Ensure the scene is safe, and do not enter if you have any doubt that it is not safe.
a.With a WMD scene, it is safe to assume you will not be able to enter where the event has happened.
b.The best location for staging is upwind and uphill from the incident.
c.Wait for assistance from trained personnel who can assess and manage the scene.
d.Remember:
i.Failure to park your vehicle at a safe location can place you and your partner in danger.
ii.If your vehicle is blocked in by other emergency vehicles or damaged by a secondary device you cannot provide patients with transportation or escape yourself.
3.Research shows that responder health and safety can suffer more than usual during WMD incidents.
a.These events can cloud decisionmaking, and paramedics can develop tunnel vision.
i.A person focuses on one aspect instead of the overall picture.
b.You need the following key resources in a potentially hazardous scene:
i.Awareness of measures to take for self-preservation
ii.A culture of safety within your organization
iii.Previous knowledge, fit testing, experience, and comfort using multiple types and brands of PPE
iv.The proper PPE
v.Self-enforcement of all protective measures
4.The best form of protection is preventing yourself from coming in contact with the agent.
a.Your greatest threat is contamination and cross-contamination.
i.Contamination: Exposure to or contact with the WMD
ii.Cross-contamination: Contact with a contaminated person who hasn’t been decontaminated
b.Decontamination is important to patients who have been exposed to or contaminated with a chemical, biologic, radiologic, nuclear agent, or explosive.
i.If EMS personnel have been trained and have the correct PPE, they may be involved in decontamination.
5.Notification procedure/resource requests
a.As soon as you suspect a terrorist or WMD event, notify the dispatcher.
b.Vital information needs to be communicated effectively.