Introduction to All-Hazards Preparedness and Planning for Terrorism
Adam H. Miller
John Munyak
Raymond E. Swienton
Phillip L. Coule
Karelene Hosford
INTRODUCTION
In this post–September 11 era, more horrific acts of terrorism will likely occur in the United States. Health care providers must be ready to respond and coordinate their actions. This chapter identifies basic definitions of commonly used terms, discusses the need for standardized education and training, provides an overview of disaster planning, and demonstrates the importance of good communication among all agencies and responders involved in disaster management. Furthermore, several essential elements vital to disaster preparation and response are reviewed in the context of an all-hazards approach.
PREPAREDNESS ESSENTIALS, HISTORIC EVENTS, AND CASE HISTORIES
There are many examples of terrorism events in or directly affecting the United States. The devastation resulting from the events of September 11, 2001, will never be forgotten. Historically, several different types of terrorism and attempts at utilizing weapons of mass effect are noted. There have been reports of failed attempts (1), numerous anthrax hoaxes (2,3), and actual attacks, such as the inoculation of salmonella into Oregon salad bars in 1984 (4), the New York City Trade Center bombing in 1993 (5), the release of sarin in Japan in 1994 (6) and again in 1995 (7), the Oklahoma City bombing in 1996 (8,9), and the U.S. embassy bombings in Kenya and Tanzania in 1998 (10).
Over the years, the increasing likelihood of the use of weapons of mass destruction (WMD) on large populations has been discussed in various official publications, from international government alerts to congressional hearings (8,18). The threat is real regarding the use of nuclear, biological, and chemical (NBC) agents and is due to the sheer number of weapons in the NBC arsenal worldwide, global security limitations, and changes in the political and overall socioeconomic status and stability of several countries (12). Although the threat of nuclear events is important, historically the use of chemical and biological agents is utilized more frequently (13,14). In addition to terrorist events and the military use of weapons, there are many examples of natural disasters including events
requiring a national response, tornados in prone regions, devastating earthquakes worldwide (e.g., in Iran and Turkey), the severe flooding and forest fires in California, and the devastation from hurricanes in the Caribbean and the United States. Volcanic eruptions, such as that of Mount Saint Helens in 1980, also demonstrated that the risk of natural disasters is real in the United States and throughout the world. All of these events have a high potential for multiple injuries and fatalities, and they all have the potential to recur and create more havoc.
requiring a national response, tornados in prone regions, devastating earthquakes worldwide (e.g., in Iran and Turkey), the severe flooding and forest fires in California, and the devastation from hurricanes in the Caribbean and the United States. Volcanic eruptions, such as that of Mount Saint Helens in 1980, also demonstrated that the risk of natural disasters is real in the United States and throughout the world. All of these events have a high potential for multiple injuries and fatalities, and they all have the potential to recur and create more havoc.
Mass casualty incidents (MCI) from events other than terrorism have identified and shaped the evolution of the disaster response in the United States. For example, when two commercial airliner crashes and a large military helicopter crash occurred over a 3-year period in Dallas, Texas, although not caused by terrorism, it significantly impacted the medical response approach in the Dallas-Fort Worth (DFW) area, as stated by Klein (15): “Working at a level 1 trauma center, we shared an attitude of complacency about disaster drills. We had a disaster plan, the available manpower, the experience, and the knowledge, and we felt confident that we could handle a local disaster. The knowledge we gained through three aircraft disasters proved to us that most of our perceptions were wrong” (15).
DEFINITIONS
Terminology such as “WMD,” “MCI,” and “all-hazards” are important to understand because they frequently have varied and broad definitions. Take the word “disaster,” for instance. Its definition encompasses the loss of life, loss of property, loss of control, and many injured or killed. A disaster has been described as an emergency that disrupts normal community function and causes concern for the safety, property, and lives of its citizens (16). The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) defines an emergency (disaster) as “a natural or manmade event that suddenly or significantly disrupts the environment of care; disrupts care and treatment; or changes or increases demands for the organization’s services” (17). Depending on the readiness and sheer ability to handle a certain magnitude of an event, a disaster is practically defined as any event that exceeds the capabilities of the response. A “disaster” is present when need exceeds resources. “All-hazards” are a collection of various human-made and natural events that have the capacity to cause multiple casualties. “All-hazards preparedness” is the comprehensive preparedness required to manage the casualties resulting from possible hazards. Frequently, events exceed the quantitative or qualitative ability of the on-site responders or receiving hospitals to treat and transport the casualties involved. This is considered a “mass casualty incident” (MCI). The term “casualty” refers to a person who is ill, injured, missing, or killed as the result of an event. And the term “incident” is used when a significant event has occurred that requires scene and casualty management (18).
Many organizations, including emergency medical services (EMS), fire, municipal, and hospital, must be integrated to provide seamless patient care from the out-of-hospital to the hospital setting. This effort will involve lay individuals such as hospital administrators, local and state emergency planners, law enforcement personnel, poison centers staff, laboratory agencies staff, industry personnel, public health officials, safety officers, and medical specialists (19,20,21,22). A seamless integration requires an approach that is quite simple yet effective.
Planning
After the terrorist attack on the World Trade Center on September 11, 2001, the disaster management community’s review of the incident identified areas of needed improvement. Among the difficulties encountered were poor communication, lack of standardized training, and inconsistent definitions of key terms, principles, and concepts including interagency jargon. The intended result of this retrospective analysis has enabled the disaster response community to remediate any such future catastrophe with better planning and ideally more favorable outcomes. The communication infrastructure must be designed with multiple levels of redundancy in order to accommodate for failure at one or more levels. Hospitals, state, and federal agencies must be able to communicate valuable information in spite of difficulties and demand on the system. During the World Trade Center disaster, communication among the Fire Department (FDNY), Police Department (NYPD), and EMS was interrupted because major equipment was located at World Trade Center tower number one. Similarly, vital organizations charged with the coordination of any disaster, such as the Office of Emergency Management (OEM), should not be located in a building that is a potential target for terrorist activities.
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