Jane’s Mass Casualty Handbook:
Pre-hospital Emergency Preparedness and Response
First Edition

Jane’s Mass Casualty Handbook: Pre-hospital is intended to help public safety agencies and their personnel prepare for, respond to and recover from mass casualty incidents.

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Topics covered include the Emergency Operations Plan (EOP), incident response procedures, crime scene considerations, explosive and incendiary incidents, chemical emergency preparedness, nuclear and radiological incidents, biological Incidents, natural disasters, manmade disasters, extended operations and system recovery in addition to training, exercises and organizational learning. Specific concerns regarding local planning, integration with federal and state planning, incident command/management, communicating with the public, incident communications, response system activation, Personal Protective Equipment (PPE), scene safety and security, search and rescue, triage, hazardous material incidents, patient decontamination, clinical management, the ‘Worried well’, consultant assistance, victim transportation, logistics and re-supply, specialty response teams, evacuation and shelter-in-place, quarantine, alternative care facilities, mass medication centers, support to the response community, patient tracking, fatality management, volunteers and donations, line of duty illness, injury and death, extended operations and incident documentation are addressed. In addition, response dispatch and arrival, mass fatality management, the PIO, demobilization and system restoration, scene safety, crime scene definition and access control, firefighting implications to crime scene requirements, evidence preservation during victim treatment and the chain of custody are also discussed as well as disarming and disposal of explosive and incendiary devices, weapon types and effects, blast injuries: symptoms and treatment, types of chemical agent attack/release, identifying the event/agent, zones of operation, crowd control, PPE, susceptible populations, radiological materials and weapons, the impact of illness on staff and operations, covert and overt incidents, diagnostic testing, surveillance techniques. Specific types of natural disaster situations are also addressed such as earthquakes, volcano eruption, hurricanes, tornadoes and flooding.

Please note that this handbook should be used to augment an organization’s existing policies and procedures as well as advice from the appropriate authorities and other relevant literature.

TABLE OF CONTENTS

PREFACE: Preparedness, Management and Response – is designed to assist responders plan for and respond to mass casualty incidents of all types, and is intended to rapidly identify critical ‘all hazards’ planning issues as well as present important action steps and response considerations.

1.0 CHAPTER 1: Emergency Operations Plan

1.1 Introduction -- effective response requires a comprehensive Emergency Operations Plan (EOP) based on a set of fundamental response principles and should include a system description and management framework.
1.2 Local planning – local planning issues are defined and discussed.
1.2.1 Planning committee -- incorporate the leadership of all frontline response agencies that have material responsibility in a mass casualty incident such as emergency management, law enforcement, fire, EMS, healthcare facilities and schools.
1.2.2 Planning approach -- a ‘systems approach’ to mass casualty response planning requires defined goals and objectives, the delineation of key planning and response assumptions, an established glossary of terms, a hazard/risk/vulnerability analysis, a response system description, a concept of operation(s), mutual aid agreements, a computerized resource inventory, training, exercises, response system maintenance and continuous system evaluation.
1.2.3 Risk assessment and hazard analysis -- local emergency response officials should periodically conduct a comprehensive assessment of the risk of a mass casualty incident and the potential for terrorism incidents.
1.2.4 Planning issues – should address topics such as terrorism, including biological, nuclear, radiological, incendiary, chemical and explosive incidents, civil unrest/disobedience, infectious disease, mass gatherings, sporting events, marches, protests, strikes, school/workplace violence, historical sites or monuments, transportation accidents and natural disasters.
1.2.5 National alert response planning -- the US government has designed a color-coded system to indicate threat level, and this system is only beneficial if response agencies determine steps to be taken when the alert status is upgraded or downgraded.
1.2.6 Pre-hospital and hospital coordination -- a ‘systems’ approach must be agreed upon for augmenting hospital security and decontamination capabilities with additional personnel, equipment and donning and doffing Personal Protective Equipment, triage, treatment and patient decontamination procedures.
1.3 Integration with federal and state planning – local plan format and concepts should parallel state and federal plans.
1.4 Incident command/management – incident management issues are specified.
1.4.1 Incident command/management systems – coordination of various response elements into a single seamless system is critical to managing any mass casualty incident.
1.4.2 Command and control -- the IMS/ICS model includes a unified command, a span of control, a chain of command, clear line and staff responsibilities, command, control, communication and coordination systems and allows for flexibility.
1.4.3 Unified management -- is critical to the control and coordination of a situation and is also referred to as integrated command or incident command management.
1.4.4 Medical Threat Assessment -- is an evaluation of the threat(s) and medical assets available.
1.4.5 Integration with the Emergency Operations Center -- coordinates the operational support required to manage an incident and implement the recovery and is also known as a Multi-Agency Coordinating Center (MACC).
1.4.6 Integration with the Joint Operations Center -- includes representatives from all local, state and federal agencies.
1.5 Communicating with the public – issues regarding communicating with the public are addressed.
1.5.1 Joint Information Center – is the most effective way to communicate with the public and is staffed by public information officials from each response agency and healthcare institution.
1.5.2 Media -- consider the benefits and implications of including members of the media in committee meetings.
1.5.3 Public education/information -- several types of information may be disseminated to the public such as emergency alert notifications, emergency directives/instructions, initial incident information, situational updates and response recommendations.
1.6 Incident communications – incident communications issues are detailed.
1.6.1 Communication planning and procedures -- communication difficulties are common during major incidents and should be planned for.
1.6.2 Medical Command -- include methods to limit the need to repeat the same message multiple times.
1.7 Response system activation -- pre-determined disaster-related questions by those taking calls can ensure critical information is received and appropriate action taken.
1.8 Personal Protective Equipment (PPE) – those using PPE should be trained in donning and doffing procedures, and safe practice while wearing specific types of PPE.
1.8.1 Characteristics of Level A PPE – gives maximum vapor and splash protection, encapsulated with self-contained breathing apparatus and is designed for the highest threat environment.
1.8.2 Characteristics of Level B PPE – is not totally encapsulated, splash protection with less vapor protection and SCBA on the outside of the suit or air supplied from external source by hose.
1.8.3 Characteristics of Level C PPE – gives less respiratory protection than Level B, either a traditional gas mask or air is drawn across filters by a battery-operated source and safe oxygen levels must be maintained in the working area.
1.8.4 Characteristics of Level D PPE – is not recommended for when hazardous material exposure is a risk and is used for basic splash/blood borne pathogen protection.
1.8.5 Advantages/disadvantages of different levels of PPE – a chart specifying the advantages and disadvantages is provided for quick reference.
1.8.6 PPE precautions – for example a safety officer should monitor personnel closely for signs of trouble.
1.8.7 Implications of PPE use -- responders’ ability to rapidly and safely triage and treat contaminated patients will be hindered.
1.8.8 Responder in-suit emergencies – always work with a ‘buddy’ when working in a hot zone.
1.9 Scene safety and security – scene safety and security issues are addressed.
1.9.1 Response personnel safety – hazards include weather extremes, extrication equipment within confined spaces and debris, long hours with inadequate rest, hydration and nutrition and the stress of working with the critically ill, injured or deceased.
1.9.2 Secondary attacks – proper steps in response to suspicious incidents include parking a safe distance from the danger area, planning an emergency egress, sweeping the scene for suspicious devices, keeping a minimum the number of personnel on-scene until it is secure, understanding that the perpetrator(s) could be among the injured or bystanders and capable of inflicting more harm, response personnel should work in groups and assigning law enforcement personnel to critical areas.
1.9.3 Site security -- establish outer and inner scene perimeters that prevent non-credentialed personnel entering the incident area.
1.10 Search and rescue -- may require specialized detection and extrication equipment such as infrared and acoustic amplification equipment, jackhammers and video cameras.
1.11 Triage – means prioritizing patient care in mass casualty incidents.
1.12 Hazardous material incidents -- may involve the accidental or deliberate release.
1.13 Patient decontamination -- patient decontamination may be required and only properly trained and protected personnel should conduct patient decontamination.
1.13.1 Gross decontamination – consists of immediate evacuation, removal of patient clothing, jewelry and personal effects and a head-to-toe rinse with water.
1.13.2 Secondary decontamination – includes washing thoroughly and systematically from head-to-toe with soap and water using a soft brush or washcloth, donning temporary clothing/cover and transfer to the treatment sector.
1.13.3 Definitive decontamination -- typically completed at the hospital and involves additional washing and rinsing.
1.13.4 Special needs patients -- require more staff and time, but often require simultaneous basic life support assistance (ABCs) while undergoing decontamination.
1.13.5 Antidotes and medications during decontamination -- may be used depending on availability, state health regulations and local protocols.
1.13.6 Communicating with patients – include pre-recorded instructions in several languages designed to be played on a PA system, laminated instruction sheets and signs using arrows to direct patients.
1.14 Clinical management – should address the medical management of casualties caused by hazardous materials found in the community.
1.15 ‘Worried well’ – persons who are asymptomatic, who were not necessarily in the immediate danger area and who are concerned about their health and safety.
1.16 Consultant assistance – appropriate consultant resources are listed.
1.17 Victim transportation – be sure to address vehicle staging, transportation sector organization, and patient assignment to transportation vehicles in planning.
1.18 Logistics and re-supply – logistics and re-supply issues are discussed.
1.18.1 Logistics -- first units on-scene should remove needed items from vehicles and place them in a designated receiving site coordinated by a resource or logistics officer as well as report to Incident Command when additional support is required and other specific needs.
1.18.2 Strategic National Stockpile (SNS) -- supplements local, regional and state medical supplies and pharmaceuticals and was established by the Department of Health and Human Services through the Center for Disease Control and Prevention (CDC).
1.18.3 Pre-positioned Equipment Program -- the US Department of Justice has created 11 pre-positioned standardized equipment pods transportable within 1–12 hours to states or other localities facing B-NICE or other major emergencies.
1.19 Specialty response teams – specialty response teams are discussed.
1.19.1 Local, state and federal resources -- can be accessed by mutual aid request.
1.19.2 Operating procedures -- planning should address how these resources are incorporated into the response operation as well as address support considerations.
1.19.3 Resource listing -- Explosive Ordnance Disposal, the fire department, EMS, law enforcement, crime scene investigators, emergency response team personnel, Special Weapons and Tactics, the Metropolitan Medical Response System and others are defined.
1.20 Evacuation and shelter-in-place – specific issues are discussed.
1.20.1 Evacuation -- address evacuation related issues, including: providing public notice; traffic flow and handling those who refuse to leave.
1.20.2 Shelter-in-place -- include preparations for conducting rapid threat assessments and initiating public warning strategies.
1.21 Quarantine – should only be used as a last resort to contain infectious outbreaks.
1.22 Alternative care facilities – planning should address the need to direct patients to clinics and walk-in facilities and to issue explicit instructions via TV/radio about who needs to receive care and where to go.
1.23 Mass medication centers -- address issues associated with mass medication such as multiple large facilities with a suitable design for maximum patient throughput, incident management structure, staffing, security, signage, medication administration procedures, communication equipment and procedures, health and hygiene support and administrative support materials.
1.24 Support to the response community -- specific issues are addressed.
1.24.1 Personal preparedness -- including emergency food and water supply, health and hygiene needs, emergency contact numbers and evacuation routes and rendezvous locations.
1.24.2 Rehabilitation and mental health -- a rehabilitation sector should be established at the incident scene in a safe and secure location.
1.24.3 Medications -- medications for responders may be required in the event of a radiological or biological incident.
1.24.4 Responder families -- concerns about the health and safety of responder’s families must be addressed.
1.25 Patient tracking -- identify the location of all patients being treated and share this information with family members.
1.26 Fatality management – be sure to address the possibility of large numbers of fatalities.
1.27 Volunteers and donations – issues involving volunteers and donations are discussed.
1.27.1 Solicited and unsolicited volunteers -- medical credentials must be verified and proper supervisory procedures put in place in order to safely utilize volunteers.
1.27.2 Donated goods and services -- effective receipt, cataloguing, storage and distribution of donated items and services requires personnel with logistical experience.
1.28 Line of duty illness, injury and death -- responders are at risk from death or injury, whether from secondary devices or sequential attacks, working in or around collapsed structures and treating patients.
1.29 Extended operations -- recognize the implications of prolonged response operations.
1.30 Incident documentation -- effective documentation procedures should be used at all levels.

2.0 CHAPTER 2: Incident Response Procedures

2.1 Dispatch and arrival – sample procedures are provided such as if on scene, review dispatch information or report observations, review relevant planning information, switch to assigned incident channel, review agent information, listen for special instructions, approach incident upwind and uphill, park a safe distance from any identified hazard or area that could endanger personnel or equipment (see DOT Emergency Response Guidebook), look for unusual sights, sounds and relocate if odor/cloud/casualties are noted.
2.2 Initial activity – a checklist is provided as a resource with procedures such as initiate IMS/ICS per department protocol, determine, announce and ensure operational units switch to designated radio channel(s), select and announce ICP location and identify, determine and announce incident site perimeters and reference identifiers as well as establish perimeter security.
2.3 Initiate rehabilitation function – checklist includes such items as assign a Rehab Officer, identify rehab division location, locate large, safe and secure location out of sight of press/media and incident scene intensity, set up area so personnel can sit/lie down and ensure availability of health and hygiene facilities.
2.4 Initiate mass fatality management – checklist includes such activities as assign a Morgue Officer, locate large, easily accessible, secure, ventilated and well lit area for body storage/examination, limit personnel entering the area, leave victims in place until law enforcement, the NTSB, medical examiner or coroner directs them to be moved and ensure each victim/body part has a triage tag.
2.5 Assign PIO – checklist includes assign PIO, along with 1-2 alternates for relief, identify press and media briefing area, identify VIP area and protocol, obtain preliminary incident information, determine press and media access limitations, provide regular briefings and special briefings and Integrate efforts with JIC.
2.6 Extended operations – provided checklist includes such activities as establish plans, logistics and finance sections, sustain an integrated management system, integrate state and local assistance, monitor weather conditions and modify the response plan accordingly, provide regular situation updates, prepare victim location information, supplement equipment and supplies and rotate staff according to a set schedule.
2.7 Demobilization and system restoration – checklist includes such activities as determine the situation is under control, release personnel on gradual basis as assignments are completed and resources not needed, maintain on-scene security, tabulate patient information, provide mental health support, handle line of duty injury, illness and death as well as rehab/repair/replace equipment and vehicles.

3.0 CHAPTER 3: Crime Scene Considerations

3.1 Introduction: scene safety -- ensure that the scene is safe from hazards caused by the incident or those created by the perpetrator(s).
3.2 Crime scene: initial actions – a checklist is provided including viewing the scene as if the first observation is also the last opportunity to gather observations and physical evidence, remembering the importance of identifying and preserving evidence, noting unusual sounds and smells, noting unusual or inappropriate comments by bystanders or witnesses, observing people and vehicles leaving/arriving, looking for damage to the surrounding environment, anticipating what items or materials could contain evidence and looking for marks, prints and debris left on the pavement or other surfaces.
3.3 Defining the crime scene – specific needs are addressed.
3.3.1 Crime scene perimeter -- make the crime scene as large as necessary in order to include all potential evidence.
3.3.2 Access control -- establish access control points along the perimeter.
3.4 Operating within the crime scene perimeter – a list of specific activities is provided, including ensuring all personnel use appropriate PPE, surveying the scene before approaching victims, following established travel routes within the scene, limiting the number of personnel operating within the perimeter, and minimizing the amount of equipment taken into the crime scene.
3.5 Firefighting implications -- rescue and firefighting activities can destroy evidence.
3.6 Evidence preservation during victim treatment – evidence preservation concerns are addressed.
3.6.1 Precautions -- all victims are potential sources of evidence.
3.6.2 Identifying and handling witnesses -- record the presence and name of individuals who witnessed the event.
3.6.3 Information to record -- record victims’ verbal comments and reports about what they may have observed, heard, experienced.
3.6.4 Victim clothing -- during assessment and treatment, minimize the amount of disturbance caused to patients and their clothes.
3.6.5 Deceased victims -- do not alter the condition of deceased victims.
3.6.6 Identifying and handling evidence – protect evidence from weather conditions with plastic or other protective materials.
3.6.7 Documentation -- document the exact procedures and treatment rendered to victim.
3.6.8 Avoid cross-contamination -- take steps to avoid cross-contamination between victims or items of potential evidentiary value.
3.7 Chain of custody – work with local and state law enforcement to develop on scene chain of custody procedures.
3.7.1 Documentation -- chain of custody documents detail where an item has been and who has had contact with it.
3.7.2 Evidence handling procedures – including no item of evidence should be left unattended or unaccounted for, evidence must be maintained in a secured manner and location, evidence should be collected and stored in sealable, tamper evident packaging and established agency procedures must be followed to ensure consistency in the handling and maintenance of evidence.

4.0 CHAPTER 4: Explosive and Incendiary Incidents

4.1 Introduction -- Explosive or Incendiary Devices (EID) are the most likely form of terrorist attack, and responders must assume the worst when responding to and managing an incident involving an EID.
4.2 Planning and preparedness – specific planning and preparedness issues are discussed.
4.2.1 Response considerations -- steps must be taken to ensure an immediate and appropriate response to the discovery of secondary devices or the possibility of a series of attacks against response personnel.
4.2.2 Categories -- there are seven main categories including victim- operated, time-delay operated, command-operated, projected, hoax, false and combination.
4.2.3 Disarming and disposal -- only qualified personnel should attempt to disarm an explosive or incendiary device.
4.2.4 Protective equipment – during all operations use tools and protective equipment appropriate to the task.
4.2.5 Specialty teams – are discussed such as Tactical Team/SWAT, Tactical EMS, Explosive Ordnance Disposal.
4.3 Weapon types and effects – specific types of weapons are detailed.
4.3.1 Types of EID* -- such as firebombs/incendiary devices, postal explosive devices, pipe bombs, man-portable explosive devices and a Vehicle Borne Improvised Explosive Device.
4.3.2 Effects -- explosive and incendiary events are relatively easy to identify.
4.3.3 Types of injury – types include primary blast injury, secondary (or ballistics) blast injury, tertiary blast injury, thermal injury, crush, debris and dust injuries and secondary contamination.
4.3.4 EID scene hazards – include secondary devices, structural collapse or potential collapse, blood-borne pathogens and hazardous materials.
4.4 Incident response – important steps are reviewed.
4.4.1 Arrival – steps include arrive and stage vehicles/units upwind and uphill, consult planning information for the address, consider building instability and potential collapse, establish a Command Post (CP) outside the inner perimeter, establish unified IMS/ICS/HEICS and be aware of secondary devices.
4.4.2 Evacuation considerations – evaluate the need to evacuate the immediate or down-range area.
4.4.3 Response precautions – do not touch, move or otherwise disturb a suspect item or its environment.
4.4.4 Triage – tips provided include assessing for traumatic injuries and underlying medical conditions and using standard triage techniques indicate patients’ priority with triage ribbon or on a triage tag.
4.4.5 Blast injuries: symptoms and treatment – are discussed such as perforated tympanic membrane, primary pulmonary blast injury, air embolism, gastrointestinal injury, secondary injuries and tertiary injuries.
4.4.6 Scene set-up and safety -- because of the risk posed by radios, automatic vehicle locators, pages, cell phones and other electronic devices, perimeter distances may be unusually large and/or personnel must be given explicit directions to turn off all of these devices.
4.4.7 Patient transport -- patients injured by EID devices may need to be taken to a burn unit instead of the closest appropriate emergency department/trauma center.
4.4.8 Fatality management -- leave the deceased in place until the incident investigation is complete.
4.4.9 Scene documentation -- documentation of an EID incident scene should be consistent with agency procedures.

5.0 CHAPTER 5: Chemical Emergency Preparedness

5.1 Introduction -- emergency response personnel are prepared to recognize accidental versus intentional incidents and take measures to protect themselves, while responding to the needs of the injured and minimizing the environmental impact of the release.
5.2 Planning and preparedness – specific needs are addressed.
5.2.1 Integrated response -- begin with a community hazard analysis and risk assessment.
5.2.2 Specialty teams – teams discussed are MMRS where available, National Guard Civil Support Team (CST), National Medical Response Team (NMRT), Marine Corps Chemical Biological Incident Response Force (CBIRF), Environmental Protection Agency (EPA), US Coast Guard Strike Team, local/state health department and local/regional military organization.
5.2.3 Response protocols -- develop protocols specifying what medications, including antidotes, should be administered to HAZMAT /WMD patient(s) and how chemical-related burns should be managed.
5.3 Chemical agents – specifics about chemical agents are discussed.
5.3.1 Type of attack/release -- may be a vapor or liquid release.
5.3.2 Agent properties -- most chemical agents are liquids.
5.3.3 Identifying the event/agent -- contamination risk can come from liquid on the ground, objects in the vicinity and/or vapor.
5.3.4 Rapid detection equipment -- is one of the most critical response elements.
5.3.5 Specimens -- should be collected, packaged and transferred to state and federal public health and law enforcement laboratories.
5.4 Incident response – issues involving incident response are discussed.
5.4.1 Initial procedures – immediate notification of first responders, healthcare facilities and public health is critical.
5.4.2 Secondary risks (fire, collapse, radiation) – include a combination of hazardous materials could cause a secondary explosion or fire, chemical agent dispersal devices may incorporate incendiary or explosive materials and biological and/or radiological agents could be incorporated into chemical release or secondary devices.
5.4.3 Site set-up procedures – steps covered include create a diagram of the site and change in situation = change in boundaries.
5.4.4 Zones of operation -- there are three zones for a hazardous material incident the hot zone, the warm zone, and the cold zone.
5.4.5 Perimeter security and crowd control -- law enforcement personnel are responsible for force protection, scene management/site security, crowd control, traffic control and evacuations, and evidence management.
5.4.6 PPE -- appropriate PPE, based on agent information, must be worn by those at risk of agent contact.
5.4.7 Evacuation and rescue -- consider carefully the benefits of evacuation from adjacent areas versus sheltering in place.
5.4.8 Triage – both the START and JumpSTART triage systems are discussed.
5.5 Treatment – specific treatment needs are detailed.
5.5.1 Initiating care -- responders dressed in appropriate PPE are responsible for the initial triage, treatment and oversight of casualty decontamination.
5.5.2 Chemical burns – characteristics and treatment are discussed.
5.5.3 Nerve agent syndrome – characteristics, treatment and considerations are discussed.
5.5.4 Chemical conjunctivitis -- characteristics, treatment and considerations are discussed.
5.5.5 Inhalational injury -- characteristics, treatment and considerations are discussed.
5.6 Patient transportation – distribute patients across area healthcare facilities in consultation with a Hospital Coordinating Center.
5.7 Susceptible populations – such as pediatric and elderly populations have specific needs.
5.8 Special considerations – specific considerations are discussed.
5.8.1 Reducing public anxiety -- broadcasting public service messages in multiple languages and using multiple mediums can help allay fears.
5.8.2 Evidence collection -- it is imperative that clothing and personal items that were bagged and tagged at the beginning of the decon process be properly identified on the outside in accordance procedure in case it is required as evidence by law enforcement.

6.0 CHAPTER 6: Nuclear and Radiological Incidents

6.1 Introduction -- possible terrorist use of a Radiological Dispersal Device (RDD), or ‘dirty bomb’, to inflict physical and psychological harm, although unlikely has recently gained significant media coverage.
6.2 Planning and preparedness -- identify fixed facilities such as hospitals, laboratories and research centers where radioactive materials are produced, utilized and/or stored.
6.3 Radiological materials and weapons – concerns, health effects and types are discussed.
6.3.1 Incident types – include accidental release, radioactive waste, accidental radiation release, terrorist attack, aerosol and a Radiological Dispersal Device.
6.3.2 Health effects of radiation -- there are three main types of radiation exposure including contamination, incorporation and irradiation.
6.3.3 Hazard identification -- the US Department of Transportation (DOT) requires all radioactive material shipments to have two warning labels placed on opposite sides of the outer package that specify the radioactive content and activity in curies.
6.3.4 Detection and monitoring devices – the most common is a Geiger- Mueller (GM) counter.
6.3.5 Safety practices and consultant expertise – key safety measures are decrease time near radiation sources, increase distance from radiation sources and increase shielding between the radiation source.
6.3.6 Protective equipment – most often those providing medical care wear Level C PPE which consists of multiple pairs of thin rubber or plastic gloves, high-density disposable polyethylene coverall with hood and foot covering or other close-weave coveralls, rubber or plastic boots, eye protection, Fit-tested negative or positive pressure respirators or a surgical mask or a fit-tested N-95 HEPA mask and personal dosimeters.
6.4 Incident response – steps for appropriate incident response are outlined.
6.4.1 Arrival -- arrive and position vehicles upwind and uphill, consult planning information for the address, look for placards, labels, markings, container shape and size, shipping papers or facility documents, establish unified IMS/ICS and assess the incident and report findings are some of the steps that should be taken on arrival.
6.4.2 Triage – some key steps for triage are assess for traumatic injuries and underlying medical conditions and keep in mind that radiation exposure/contamination is a secondary concern, preliminary prioritization using standard triage techniques using either START or JumpSTART, radiation detection and monitoring devices should be used to determine the degree of exposure and medical care for traumatic injuries should not be delayed.
6.4.3 Patient decontamination – steps for external and internal decontamination are covered.
6.4.4 Acute Radiation Syndrome (ARS) -- also known as radiation sickness, occurs when the body receives a high dose of radiation in a short period that reaches the internal organs and is characterized by four distinct phases, specifically, prodromal, latent, illness and recovery or death.
6.4.5 Medical care -- skin or wound contamination is rarely immediately life threatening, therefore, patient stabilization is the priority.
6.4.6 Patient transport – key steps such as patients should be wrapped in water repellent dressing to reduce the possibility of cross contamination are listed.
6.4.7 Fatality management -- bodies should not be removed until directed by investigation personnel.
6.4.8 Demobilization considerations -- radiation incident scenes may require lengthy environmental cleanup.

7.0 CHAPTER 7: Biological Incidents

7.1 Introduction -- characteristics of a biological event are listed including such things as heightened community anxiety and escalating patient presentation as exposure and illness spread.
7.2 Planning and preparedness – specific steps are reviewed.
7.2.1 Public health authorities -- roles and responsibilities and state and federal resources are outlined.
7.2.2 Illness impact on staff and operations -- reduce the risk of personnel becoming exposed and ill before an incident outbreak the agent has been identified it is imperative that response personnel who identify unusual illnesses, or clusters/patterns of illness report any suspicions.
7.2.3 Public information – an immediate response to address public concerns and provide reassurance in order to reduce fear and prevent panic is required.
7.2.4 Mass prophylaxis -- involves providing vaccinations or antibiotics to a large population in a short period of time.
7.3 Biological agents -- naturally occurring biologic agents can cause individual or widespread illness.
7.4 Biological incidents – concerns regarding biological incidents are discussed.
7.4.1 Types of incident – possible biological types include bio-terrorism, overt, covert, natural disease outbreaks, accidental biological incidents and bio-terrorism hoaxes.
7.4.2 Delivery/dissemination -- possible delivery mechanisms include aerosols, sophisticated bomblets or crude bombs and an aircraft spraying a liquid or dry agent, or an individual(s) disseminating the agent from, for example, a two gallon garden sprayer while walking or driving.
7.4.3 Incident recognition – a covert event may not be immediately recognized and unannounced index patients may present with non-specific symptoms similar to other more common ailments.
7.4.4 Overt recognition – specific types covered in this section are accidental and deliberate.
7.4.5 Diagnostic testing -- field diagnostic tests have been shown to produce the occasional unreliable result and cannot be relied upon.
7.4.6 Surveillance techniques -- first responders have an important role in disease surveillance and identification.
7.5 Overt incident response – specific concerns are discussed.
7.5.1 Incident scene outbreak investigation – steps include the scene of a pathogen outbreak or release will be identified, there may be single or multiple sites, the incident scene should be treated as a HAZMAT situation, EMS will not be on-scene except to transport any remaining victims and to provide health and medical support to responders and on-scene operations should implement an integrated IMS/ICS.
7.5.2 Pre-arrival -- assessment begins before responders arrive on-scene.
7.5.3 Arrival -- self-protection must be the priority at the scene.
7.5.4 Incident response -- site set-up procedures for an overt biological release are the same as for a chemical release such as the creation of hot, warm and cold zones.
7.5.5 Triage -- triage of biological casualties may differ from traditional trauma situations in important ways.
7.5.6 Infection control – the use of standard infection control practices is more important than highly specialized precautions.
7.5.7 Decontamination -- patients exposed to pathogens will not generally undergo decontamination.
7.5.8 Treatment -- EMS care for biological victims will be supportive.
7.5.9 Transport, notification to receiving facility -- receiving facility should be given as much information as possible about patients’ conditions, treatment or other measures initiated and possible contamination or contagion.
7.5.10 Fatality management – in a short period of time a biological incident may produce significant numbers of fatalities.
7.5.11 Control of animal or insect vectors -- animal or insect vectors can be a source of natural outbreaks or of the introduction or persistence of deliberately introduced diseases.
7.6 Post-incident – post-incident concerns are discussed.
7.6.1 Follow-up medical care and reporting for frontline responders – responders exposed to communicable or hazardous biological agents must identify themselves.
7.6.2 Community recovery -- there will be questions about the safety of contaminated areas, and the community will need reassurance.

8.0 CHAPTER 8: Natural Disasters

8.1 Introduction -- there is a greater risk that a community will be affected by a natural disaster than a terrorist attack or manmade disaster.
8.2 Planning and preparedness – most communities already know the type of event to which they are vulnerable.
8.3 Safety and security -- specific safety and security considerations for natural disasters are discussed.
8.4 Evacuation and rescue -- natural disasters pose a number of rescue challenges requiring specially trained and equipped personnel.
8.5 Triage and treatment – specific steps for triage and treatment are discussed.
8.5.1 Initial triage -- standard triage systems such as START and JumpSTART should be used, triage should be initiated at the incident scene and patients then moved to a secondary triage and treatment sector and lastly, reassess each patient and initiate medical care based on the patient’s condition and available equipment and supplies.
8.5.2 Evacuation and transport -- evacuate patients on a priority basis, rotate patients evenly between nearby and distant hospitals, it may be preferable to take select victims to a casualty collection center or field hospital alternative care facility and address EMS support to field treatment locations as well as the transportation of patients to hospitals.
8.5.3 Medical care -- degree of medical care rendered on-scene and enroute to the hospital depends on several factors.
8.5.4 Special considerations -- patients with special needs have requirements that must be met using traditional and non-traditional solutions.
8.6 Natural disaster response considerations – are covered in this section.
8.6.1 General planning issues -- an all-hazards approach to planning should include addressing the needs of large numbers of casualties in high-density population areas, special medical problems caused by dust, contaminated food and water, and loss of utilities, fuel fed fires, damage from high winds as well as specific transport difficulties.
8.6.2 Earthquakes – specific issues include little to no forewarning, building and roadway collapse, seismic damage to buildings, damage to waterlines, aftershocks and special rescue equipment and trained personnel may be required for confined space rescue.
8.6.3 Volcano eruption – concerns include a need to warn the public, limited ability to predict an eruption, deteriorating environmental quality, need for continuous use of respiratory and eye protection by responders and the general public, vehicle and mechanical equipment failure, structural instability, dust, ash and other volcanic debris obscuring signs, roadways, outdoor animal acute and long-term illness/injury and and inability to use aircraft for response assistance.
8.6.4 Hurricanes – challenges include forecasting of hurricanes, incomplete or delayed evacuation, local citizens and outside visitors coming into the area for a ‘hurricane party’, heavy rain and flooding and identification of appropriate shelters inland.
8.6.5 Tornadoes – concerns include limited warning ability and an immediate need to relay warning to the public, varying degrees of damage within the same area, widespread damage and victims trapped in debris.
8.6.6 Flooding (torrential rain, hurricanes or snow/ice melt) – concerns include limited forewarning ability, need for boats and helicopters to affect rescue and special rescue techniques.
8.6.7 Heat and cold extremes and blizzards – concerns include severe weather forecasting, special vehicle preparation, additional medical equipment required and roadway obstructions.
8.6.8 Wild land fires – subjects covered are issuing timely warnings to the community, special vehicle preparation and/or need for specialized vehicles, personnel with special equipment required and the fact that air-to-ground coordination is required.

9.0 CHAPTER 9: Manmade Disasters

9.1 Planning and preparedness -- manmade disasters create a number of response issues that require effective planning.
9.2 Safety and security -- general safety and security measures are covered in this section.
9.3 Initial response -- incident scenes spread over a large area should be divided into smaller physical/geographic sectors.
9.4 Evacuation and rescue -- some victims will need to be rescued, but victims able to flee the danger area should be directed where to go and what to do.
9.5 Triage and treatment -- locations will vary by incident and may have to be duplicated when multiple patient escape routes are used.
9.6 Transportation accidents – specific concerns are addressed.
9.6.1 Large-scale multi-vehicle accidents -- incident characteristics and response concerns are covered in this section.
9.6.2 Train accidents -- incident characteristics and response concerns are covered in this section as well as security issues.
9.6.3 Aircraft: fixed-wing accidents -- incident characteristics and response concerns are detailed in this section as well as security issues.
9.6.4 Aircraft: rotor-wing accidents -- incident characteristics and response concerns are covered in this section as well as security issues.
9.6.5 Subway accidents -- incident characteristics and response concerns are covered in this section.
9.6.6 Bus accidents -- incident characteristics and response concerns are covered in this section.
9.6.7 Marine passenger vessels -- incident characteristics and response concerns are covered in this section.
9.7 High-occupancy building incidents -- incident characteristics and response concerns are covered in this section in detail.
9.8 School and workplace violence -- incident characteristics and response concerns are covered in this section.
9.9 Mass gathering events – specific incident characteristics and response concerns are covered in this section.
9.10 Hostage/barricade situations – detailed incident characteristics and response concerns are covered in this section.
9.11 Civil disobedience – specific incident characteristics and response concerns are covered in this section.

10.0 CHAPTER 10: Extended Operations and System Recovery

10.1 Extended operations considerations -- planning for extended operations and the implementation and coordination of system restoration and recovery is equally as important as mitigation, preparedness and response.
10.1.1 Incident site – specific steps include action plan writing and implementation, shift change personnel briefings, personnel health and hygiene, agent/pathogen test result sharing, criminal investigation and environmental monitoring.
10.1.2 EOC operations – steps include staff schedule/rotation, staff credentialing, safety officer regularly assessing for signs of stress, action plan writing and implementation, staff shift briefing and communication system support.
10.1.3 Personnel management – key concerns include an accountability system, work schedules, rotation, absenteeism, injury/illness, line of duty death, family support, coordination of mutual aid support and integration of state/federal resources.
10.1.4 Equipment -- key concerns are the restoration or supplementation of equipment, special needs requests, regular maintenance, replacement, electricity, food, telephones and such, as well as vehicle maintenance/fueling.
10.1.5 Re-supply – responsibilities include medical supplies, medications, rescue equipment, food/water and on-scene hygiene quarters.
10.1.6 Normal emergency operations – include staffing, routine call prioritization procedures, vehicle/personnel availability and alternative transport utilization.
10.1.7 Shelters – requirements include staffing, food/water, hygiene facilities, facility maintenance/cleaning, mental health support and situation reports for families.
10.1.8 Information sharing -- communication with community groups is required, including response agencies, responders/families, hospitals and medical community, press and media, patients/families and the incident community.
10.1.9 Documentation – document the following: critical incident management decisions, costs incurred and resource requests/response.
10.2 Demobilization -- demobilization decision-making process should be outlined in the response plan as well as modified for each incident.
10.3 Site cleanup -- site cleanup may be lengthy and require that logistical, financial and legal issues be addressed, as well as special security.
10.4 Medical surveillance -- every victim of a deliberate or accidental hazardous material incident must be entered into a registry and monitored.
10.5 Restoration of normal emergency services – criteria for determination of when normal response procedures can resume is listed.
10.6 Community health and safety concerns – the public will look for reassurance that they and their homes, businesses and community are safe and protected.
10.7 Mental health management – an acute and long-term need for psychological assistance for victims, their families and the community will exist.
10.8 Responder family support -- families may require support in order to enable responders to continue working during and after an incident.
10.9 Other system recovery and restoration considerations -- the completion of different phases of the incident must be announced to responders and the public, and post-incident critiques and After Action Reports (AAR) should be conducted.

11.0 CHAPTER 11: Training, Exercises and Organizational Learning

11.1 Training -- public safety, public health, healthcare facilities and emergency management must meet training standards required by applicable local, state, federal and nongovernmental regulatory agencies.
11.2 Functional exercises – specifics of functional exercises are discussed.
11.2.1 Full-scale training -- the most effective method of applying classroom training.
11.2.2 Exercise planning -- a representative exercise planning committee is an effective way to share the workload, shorten planning time and ensure buy-in.
11.2.3 Planning steps – a systematic approach to disaster drill planning is best.
11.2.4 Scenario -- the scenario should address all objectives, be realistic and be of appropriate severity.
11.2.5 Exercise evaluation -- use an evaluation tool and process to evaluate both the exercise as well as the performance of the disaster plan.
11.2.6 Victims -- must be recruited, made familiar with the script, and be staged for realistic presentation.
11.2.7 Safety plan – should address any safety concern that could arise during the exercise.
11.2.8 Public reassurance -- easily read placards or large signs should be placed in prominent areas and handouts provided to nearby residents.
11.2.9 Critique and debriefing – conduct a ‘hot-wash’ critique by key personnel immediately after the exercise.
11.2.10 Community-wide training and exercises -- once a year all members of the response community should participate in the development and implementation of community-wide training and exercises.

Acronyms – definitions of acronyms used in this document are provided for clarity.
Index