The material contained in this plan is sensitive and should not be distributed without the consent of health departments and emergency management agencies within the Los Angeles County Operational Area.
CHEMPACK Deployment Plan for Los Angeles County
History of Chemical Weapons
The widespread use of chemical weapons in warfare started in World War I. All nations involved in that war used chemical weapons at one stage or another. Many different agents were used, including Chlorine, Phosgene, and Mustard gas. The first major use of a modern chemical weapon was by the Germans at the Battle of Ypres in 1915. Artillery shells filled with deadly Chlorine gas were fired at French and allied Algerian troops with devastating effect. With the effectiveness of chemical weapons proven by that attack, all nations involved in the war scrambled to build their chemical arsenals, and develop defensive countermeasures against chemical attacks.
This attention to chemical warfare defenses produced significant results towards the end of the war; as the war progressed, chemical attacks became less and less effective. The reason for this was improved protective equipment and training measures adopted by all military forces. The improvements in defensive countermeasures led to a change in tactics for those who continued to use chemical weapons. Rather than using chemical agents against soldiers, they began to target civilians. Civilians did not have access to the training and protective equipment of military personnel, which left them vulnerable to chemical attack.
This alternative tactic of attacking civilians has been used many times during this century. Nerve agents were used by Iraq against Iran in the 1980s, and again by Saddam’s regime on Iraq’s native Kurdish population. More recently, in 1995, the Japanese cult, Aum Shinrikyo, used nerve agents in an attack on Tokyo’s subway system. Eleven people died and approximately six thousand patients were seen by local hospitals that day. Thus, chemical weapons have been transformed from weapons of warfare to be used against soldiers into agents of terror deployed against civilians.
Purpose of this Plan
In the event of a terrorist attack employing chemical nerve agents, the County of Los Angeles must be prepared to respond quickly in order to save lives. Unlike many other chemical or biological agents, which may not produce ill effects for hours or days, the time frame for an effective response to a nerve agent attack is measured in minutes. The CHEMPACK program created by the Centers for Disease Control (CDC) was designed to place nerve agent antidotes in communities all over the country to support a quick response to a nerve agent attack. There are two types of CHEMPACK containers: the EMS CHEMPACK and the Hospital CHEMPACK. EMS CHEMPACK materials are designed for pre-hospital medical providers, and the antidotes contained in the EMS CHEMPACK are mostly auto-injectors for speed and ease of use. The Hospital CHEMPACK is designed for hospital medical staff, and the antidotes contained in the Hospital CHEMPACK are primarily multi-dose vials.
CHEMPACK Deployment - General
Los Angeles County is a participant in the CHEMPACK program. The CHEMPACK containers will be placed in facilities called Disaster Resource Centers (DRCs). DRCs consist of select hospitals geographically distributed throughout the county, which have an upgraded disaster response capability. Also selected as CHEMPACK location sites are certain fire stations and the county’s Disaster Staging Facility (DSF).
There are a few factors that make responding to a nerve agent attack in Los Angeles County challenging. First, terrorist attacks are very hard to predict. An attack could happen anywhere in the county, at any time. As mentioned above, there is also a narrow time frame for an effective response to a nerve agent attack. Finally, even at the best of times, traffic and congestion on Los Angeles roads and freeways is a problem. However, in the chaos immediately following a terrorist attack, traffic would be many times worse. Issues such as these demonstrate the need for an effective response plan to reduce confusion and potentially counter-productive improvisation among emergency responders by bringing about an effective, organized response to a nerve agent attack.
The County of Los Angeles Department of Health Services, Emergency Medical Services (EMS) Agency is the lead agency for disaster response for coordinating the medical and health response. The EMS Agency has communications and command and control capabilities not available to most other agencies. The EMS Agency can coordinate the actions of hospitals and fire departments across the county, and has an emergency communications system already in place.
However, in the case of a terrorist attack using nerve agents, strict adherence to a chain of command may slow down response time, with tragic consequences. This traditional EMS response to disasters is not flexible enough to respond to a nerve agent attack. The need for a quick response requires a more adaptable and less rigid response plan. T he Los Angeles County EMS Agency has the authority to order deployment of CHEMPACK materials in response to an attack; however, the county’s DRCs and other location sites will also have authorization for CHEMPACK deployment in an emergency, thus saving time and lives in the process. In the event that a DRC deploys its CHEMPACK resources in an emergency, the EMS Agency will coordinate the overall response. In a field setting, where the incident scene involves a public area, the local fire department would be in charge of transporting the CHEMPACK, while the local police department would be responsible for force protection. In a hospital setting, where the first signs of an attack were an otherwise unexplained surge of affected patients at a local hospital, the transportation arrangements would have to be made between the DRC and the affected hospital, if the impacted facility was not a DRC.
CHEMPACK Deployment - Specific
There are four different scenarios for CHEMPACK deployment:
- EMS agency initiated field deployment
- EMS agency initiated hospital deployment
- DRC initiated field deployment
- DRC initiated hospital deployment
Scenario #1 would be when the EMS Agency orders deployment of CHEMPACK resources to an incident site in a public area. This would occur in the case of an overt nerve agent release in a populated area such as a stadium or inside a building. Scenario #2 would most likely involve a covert attack, where the first signs of an attack were an otherwise unexplained surge of patients seeking treatment for symptoms indicating nerve agent exposure. In this scenario, the affected hospital contacts the EMS Agency and requests CHEMPACK resources. Scenario #3 is the overt attack scenario, but in this case the DRC initiates CHEMPACK deployment instead of the EMS Agency. Scenario #4 involves a covert release as mentioned above; only in this case the affected hospital contacts the local DRC for CHEMPACK deployment.
In any of these scenarios, both the DRCs and the EMS Agency have authority for deployment. The deployment can happen immediately, as long as the incident meets the conditions for deployment. T here are two conditions that need to be met for deployment of a CHEMPACK. One is that the incident must be a true mass casualty incident, with at least fifty patients affected. The other is that a nerve agent must be responsible for the casualties.
In the case of an overt nerve agent release in a public area, where the EMS Agency is contacted first, response would most likely occur as follows: local fire and police responders would converge on the scene (in a mass casualty situation the Incident Command System (ICS) would be activated and used). There must be at least fifty patients for the incident to qualify as a mass casualty incident and thus meet the threshold condition for CHEMPACK deployment. The first responders would determine by scene investigation and by observing patient signs and symptoms that a nerve agent is responsible. The Incident Commander (IC) would then notify the EMS Agency. This would trigger the EMS Agency’s terrorism notification protocol.
The IC must decide if first responder resources are sufficient to handle the incident or if additional resources are needed. If additional resources are needed, the IC would contact the EMS Agency and request deployment of an EMS CHEMPACK. The EMS Agency would contact the closest DRC to the incident, and instruct them to prepare their EMS CHEMPACK for deployment. The local fire department would be responsible for transport of the CHEMPACK to the scene for use. The police department would be responsible for force protection and scene control.
In scenario #2, the hospital would notify the EMS Agency of a possible terrorist attack, and if the hospital’s resources were adequate to deal with the patient load, no other assistance would be requested. However, the EMS Agency would implement its terrorism notification procedures and continue to monitor the situation. If the hospital required additional resources, staff would request deployment of a Hospital CHEMPACK from the EMS Agency (again, there must be at least fifty casualties to qualify for CHEMPACK deployment). The EMS Agency would then contact the closest DRC and instruct them to prepare a Hospital CHEMPACK for deployment. The requesting hospital would be responsible for making arrangements to transport the CHEMPACK.
In scenario #3 or #4, CHEMPACK deployment could be initiated by any of the county’s DRCs. The procedures for deployment are similar to the EMS Agency initiated deployment procedures detailed above, except that the local DRC would be the first agency contacted and would initiate deployment. Many of the Los Angeles County DRCs are paramedic base hospitals, and these locations may be contacted first by paramedics in the field who have responded to a terrorist attack. Therefore, it is important that they have the authority to initiate CHEMPACK deployment. Also, the DRCs are connected with all other hospitals in the county via the ReddiNet communications system. As a result, any hospital in the county can contact the DRC in an emergency.
If a DRC is the first agency contacted, it may deploy the CHEMPACK on it’s own. However, the DRC must still notify the EMS Agency of a terrorist attack. The EMS Agency would be the lead agency for medical and health disaster response and therefore must be notified of an incident so that it can coordinate the county’s response. In a field setting, the fire department would still be responsible for transport of the CHEMPACK to the incident scene, and in a hospital setting, arrangements must still be made by the requesting hospital for transport. All four scenarios and their responses are illustrated by flowcharts, which follow.
Color-coding and Distribution System
Each DRC within Los Angeles County will, during an emergency deployment of a Hospital CHEMPACK, be responsible for supplying up to three other hospitals within it’s area with nerve agent antidotes. Thus, each DRC will be expected to supply up to four hospitals (including the DRC). The cases within each Hospital CHEMPACK that contain medications shall be divided up four ways and color-coded using color labels. The DRC will keep all the auto-injectors at its location, only the packages containing medications that come in multi-dose vials will be divided four ways. Also, extra packages remaining after division will stay at the DRC. At the time of an emergency, the DRC will quickly designate which stock goes to which hospital. Each colored label represents a certain destination hospital, so all the cases going to a certain hospital will have the same color label.
EMS CHEMPACKS will also be color coded, but they will be color-coded by item, not by destination, as all supplies will be provided to the field location of the event. Each medication within the EMS CHEMPACK will be assigned a color, and labels with that color on them will be placed on each case containing that particular medication.
The color-coding schemes are illustrated below. As stated above, in the case of hospital CHEMPACKS, the method of transportation must be arranged by the requesting hospital.
Color-coding Scheme for EMS CHEMPACKS
1. Mark I, auto-injectors Yellow
2. Diazepam, auto-injectorsGreen
3. Pralidoxime Red
4. Atropine, multi-dose vialsBlue
5. Diazepam, multi-dose vialsOrange
6. Sterile Water for injection vialsWhite
7. Atropine 0.5 mg, auto-injectorsPurple
8. Atropine 1.0 mg, auto-injectorsGrey
Breakdown Scheme for Hospital CHEMPACKS
DrugNumber of CasesDistribution
Mark 1, auto-injectors 2 Stays at DRC
Atropine multi-dose vials9DRC 3, hospitals 2,2,2
Pralidoxime multi-dose vials10DRC 4, hospitals 2,2,2
Atropine 0.5 mg, auto-injectors1Stays at DRC
Atropine 1.0 mg, auto-injectors1Stays at DRC
Diazepam, auto-injectors1Stays at DRC
Diazepam, multi-dose vials26DRC 8, hospitals 6,6,6
Sterile Water for injection, vials28DRC 13, hospitals 5,5,5
Color-coding Scheme for Hospital CHEMPACKS
LocationColor Assigned
DRCNot Labeled
Hospital #1Blue
Hospital #2Green
Hospital #3Yellow
Distribution Flowchart for Hospital CHEMPACKS
Flowchart for EMS Agency Initiated CHEMPACK Field Deployment
Flowchart for EMS Agency Initiated CHEMPACK
Hospital Deployment
Flowchart for DRC Initiated CHEMPACK Field Deployment
Flowchart for DRC Initiated CHEMPACK Hospital Deployment
3/21/2005FINAL WORKING VERSION13-A1