Ebook: Medical Response to Terror Threats

This book, Medical Response to Terror Threats, provides expert analysis to professionals across diverse disciplines who share a common interest in ensuring that our medical and health communities understand how to mitigate, manage, and respond to hazards, threats, and injuries caused by terrorism.

It is based on the NATO Advanced Research Workshop that took place in Jerusalem, Israel, on December 7-9 2008. This two-and-a-half-day event was organized by the Terror Medicine International Center, the Interdisciplinary Center for Technological Analysis & Forecasting, and the Institute of Terrorism Research and Response.

The Workshop was designed as an executive-level, educational event for medical professionals. It created a space to share scholarship and provided networking opportunities between attendees and the participating Subject Matter Experts.

The Workshop covered the following topics:

Assessment of the medical threat of various types of terrorist attacks; conventional and non-conventional

The special medical threat of suicide bombings

Review of the unique epidemiology associated with terrorist attacks

Pre-hospital and hospital management of terror-related Mass Casualty Events (MCE)

Analysis of case studies and presentation of best practices

Lessons learned and Standard Operating Protocols (SOP) expertise

On behalf of the International Center of Terror Medicine, the Institute of Terrorism Research and Response, and the Interdisciplinary Center of Technological Analysis and Forecasting, we thank our NATO delegates and the participants. We also thank you the reader for your interest in this book and invite you to join us for future workshops and seminars.

The Editors and Co-Directors of the Workshop,

Aaron Richman

Shmuel Shapira

Yair Sharan

Terror medicine is defined as a planned medical response to terror attacks. A model for establishing a terror medicine program is presented. Methods are provided for confirming the validity of a terror medicine program.

Bioterrorism is defined and its function in the terrorist arsenal is explored. The US government’s response to the dangers posed by bioterrorism is chronicled historically and an assessment is made of the current level of preparedness within the United States.

A major obstacle to US national preparedness is determined to be legal restraints that inhibit effective response methods such as quarantine. As these legal constraints are considered, it is concluded that a proactive effort must be made to resolve outstanding legal questions and strike a balance between public safety and civil liberties before a bio-terror attack tests the apparent weaknesses of the current system.

Radiological terrorism is distinguished from other forms of terrorism and its most significant physical and psychological effects are noted. A detailed model for immediate response and long term recovery is illustrated. A single page guide containing key points in planning for and managing radiation injuries is included for easy reference. It is concluded that training and regular drills are essential to prepare for radiological terrorist attacks.

The 2001 anthrax dispersion through the U.S. mail system is recounted and considered. Lessons that were imparted by the incident are revealed and catalogued. Challenges and surprises that were presented by the incident are examined in order to prevent them from being repeated. Critical information is determined to facilitate preparation and response for future attacks which may be similar in nature.

Existing measures employed by the United States hospital system for the response to terror attacks are detailed at length. The Philadelphia area hospital system is used as a prime example. Programs such as: ICS – the Incident Command System; NIMS – the National Incident Management; CHEMPACK; SNS – the Strategic National Stockpile; and DMM – the Disaster Medicine and Management Masters Program are thoroughly described. Conclusions are drawn about the strength of these programs in relation to the threat of terrorism.

Disaster response is considered in relation to terrorist attacks. The challenges involved in disaster response are broken down and weaknesses in the current system of guidelines are revealed. A historical example of disaster response is provided and examined in depth. Improvements are suggested in order to remedy existing systemic vulnerabilities.

The trauma system in Iraq has evolved to deliver advanced pre-hospital care, rapid road or aero-medical evacuation (AME), early initial wound (damage control) surgery at a forward operating base and then secondary assessment, further resuscitation more specialised damage control surgery at the major field hospital. This is a Level 1 Trauma Centre and includes computed tomography (CT) scan, intensive care unit (ICU) and the full complement of surgical specialists including a head and neck team and consultant radiologists. When stabilized, the patients are transported with ongoing intensive care to Germany and then to the US. The mortality of battle injuries has reduced progressively since World War II (WWII) and is now approximately 10% in the Iraq war which is at the lowest level ever recorded; a remarkable achievement considering the severity of blast injuries. The reason for the reduction in mortality will be discussed. The management of severe blast injuries and mass casualties within the military hospital in Iraq is presented. Blast injury results in polytrauma with penetration from metal fragments and other foreign bodies, blast wave injury to internal organs and extremities and burns including respiratory burns. Blast lung injury is very common following blast exposure and increases the complexity of management in the operating room and ICU environment. This severe multiple trauma produces gross physiological compromise and requires trauma care of the highest order in order to save lives and reduce morbidity. These problems are infrequently encountered in the civilian sector. There are many lessons in how these casualties are managed in a military hospital which inform the management of blast injury and severe multi-trauma casualties in the civilian sector.

The topic is a very serious one, and most intricate too. I shall endeavor to share with you a bird’s eye view of several points and aspects concerning biological terrorism. To be more precise: certain ethical and practical aspects in the domain of Bioterrorism, Biosecurity, and Biosafety – War on Terrorism and preparedness for such an outbreak.

This paper will consider the issues that affect UK medical responses to terrorism. It will place the medical response to terrorism in the context of the UK response to any major incident, and contrast responses to terrorist attacks with responses to other medical emergencies in the UK. In doing this, it will focus specifically on the elements within such responses that are unique to terrorism.

The first part of this paper will outline the legislation and guidance covering major incident response in the UK at the national, regional and local level. The Civil Contingencies Act 2004 will be considered in its context as the national framework for managing major incidents, and the national guidelines of the UK Government’s Department of Health, the National Health Service (NHS) and the Health Protection Agency (HPA) will also be discussed. At the regional level, London will be taken as a case study, outlining the roles of the London Resilience Team, the London Emergency Services Liaison Panel (LESLP) and the London Ambulance Service (LAS) in the medical response to terrorism. At the local level, the plans and response procedures relating to individual hospitals will also be examined.

The paper will then discuss how the medical response to terrorist incidents differs from the response to other major incidents, looking in particular at the number of casualties; the type of injuries; the command and control challenges of dealing with multiple incident sites; and the need to consider that the incident site is also a crime scene. Particular consideration will be given in this section to planning for and responding to a chemical, biological, radiological or nuclear (CBRN) attack.

The second part of the paper will explore the UK medical response to terrorism in more detail by focusing on two recent case studies: the 7 July 2005 suicide bombings on London’s public transport system and the poisoning of the former Soviet agent Alexander Litvinenko with the radiological isotope Polonium-210 in November 2006. These case studies will be used to identify specific challenges that arose during these responses. The unique challenges presented by each case will be directly contrasted with those of the other to show that a single medical response framework cannot deal with all terrorist incidents: different types of attack present different challenges that require different responses.

The paper will also consider the long-term psychological effects of terrorism and the healthcare provisions that need to be made before, during and after the incident, including the need for a robust system for recording those who may require follow-up health and psychiatric care to enable the availability of this care to be communicated to them.

The increase in the use of the suicide bomber tactic globally calls for an immediate assessment of current emergency response practices, including policies relating to: lockdown, emergency notification and communication, and active shooter tactics within a suicide bomber incident. The adversary is utilizing very clear strategies and tactics that have been proven over time. The capability and intent of the adversary are present. Order needs to be put into place at the local and state level under the guidance of the federal government for a standardized policy for handling suicide terrorism. This paper will discuss the viewpoints of response considerations to suicide bombing incidents and will evaluate the aspects associated with the numerous response models and associated hazards. In addition, the importance for law enforcement agencies to have an operating procedure will be addressed, as well as the impact on the development of a standard for effective responses to such a lethal mass casualty incident.

Trends in the proliferation of terrorism are examined and determined to point toward imminent escalation. Timetables for this projected escalation are provided. Current trends in science and technology are used to predict the forms this escalation of terrorism could take. A determination is made that there is a compelling likelihood that terrorists will be willing and able to obtain and employ these future technologies. It is concluded that safeguards are required in certain scientific and technological fields in order to avert the current risk.

Coping with risk situations in hospitals can be complex and controversial. Government and industries have devoted considerable resources to develop and apply techniques of risk analysis and risk characterization in order to make better informed and more trustworthy decisions about security threats to human health, welfare and the environment.

Risk analysis methods often fail to meet the expectation of being able to improve decision making. One reason lies in the inadequacies of available techniques for analyzing risks. In recent years, awareness of the fact that hospitals may be targets of terrorism attacks has increased. In addition, security awareness in hospitals and associated health centers has increased in western countries. This article pays special attention to technology related risks and threats in hospitals by analyzing systemic aspects of security technology and associated risks in hospitals. The systemic analysis is done separately on hospital systems and on surrounding environmental systems.

Typical risk and threat analyses are performed by combining STEEPV methodology and SWOT-analyses. This kind of quite simple but flexible methodology is a promising tool in the analysis of risks and systemic aspects of security technology in hospitals. Relevant wild cards of hospital services relying on available security technologies are discussed widely.

In short, the STEEPV-SWOT methodological approach includes four phases: (1) Weak signal identification related to the internal and external STEEPV systems of a hospital, (2) Listing the most challenging systemic STEEPV Wild Cards, (3) SWOT analyses on STEEPV wild cards, (4) Risk and security management plan based on systemic SWOT analyses of the most serious and risky wild cards. It is important that hospital stakeholders are active partners in this risk management and security analysis process.