Aug. 10, 1999 Washington, DC -- Saying it's not just a matter of "if" but "when," America's emergency medical community is preparing to respond to potential acts of terrorism in the United States, according to the August issue of Annals of Emergency Medicine. Several articles discuss the history and threat of attack, the status of emergency medicine training, and the risks for the emergency medical community. A new study of medical records from the Oklahoma City bombing confirms that emergency responders must be prepared for two waves of patients after a terrorist attack.
Copies of the articles may be obtained from the Washington Office of the American College of Emergency Physicians.
EMERGENCY PHYSICIANS AND BIOLOGICAL TERRORISM
The article presents the history and threat of biological weapons and discusses planning and response issues central to a potential bioterrorism event. It describes how recent developments have heightened fears of terrorist attacks, such as the bombings of the World Trade Center in 1993 and the federal building in Oklahoma City in 1995, the sarin attacks in Tokyo and Matsmoto, Japan, and the U.S. Embassy bombings in Kenya and Tanzania in 1998.
"A biological attack on a major city could approximate the lethality of a nuclear explosion," said Christopher F. Richards, MD, of the Brigham and Women's Hospital Department of Emergency Medicine in Boston. "Without awareness and planning, a bioterrorism event may go unrecognized or dismissed as a natural epidemic until it becomes catastrophic. In the event of an actual incident, emergency physicians will become first responders in recognizing and managing the response."
Dr. Richards, also an instructor at Harvard Medical School, said the American College of Emergency Physicians has convened a task force of health care professionals, representing those who will be central to responding to a bioterrorism incident, to examine educational goals and strategies, curricula, teaching methods, and certification processes to better prepare "frontline" health care professionals.
EMERGENCY DEPARTMENT IMPACT OF THE OKLAHOMA CITY TERRORIST BOMBING
A new study of medical records from 388 victims of the 1995 bombing in Oklahoma City -- the largest terrorist incident within the United States to date -- provides information on the medical impact of such bombings, which may aid effective planning and help reduce injury in a terrorist attack.
The study found that more than half the patients arrived in emergency departments by privately owned vehicles, converging on geographically closest hospitals as the first wave of patients, consistent with prior reports of terrorist bombings. Victims arrived within 5 to 30 minutes after the bombing, with more seriously injured patients taking longer to arrive than patients treated and released, supporting previous studies which found that more seriously injured patients arrive in a "second wave."
"Emergency health care providers are responsible for the initial medical response to mass casualty incidents caused by all forms of disaster, including terrorism," said David Hogan, DO, of the University of Oklahoma Department of Emergency Medicine. "Emergency departments must be prepared to rapidly triage and distribute victims in the first wave while preparing for potentially more critical patients in the second wave. The high frequency of non-emergency medical services transport points out the difficulties of controlling patient triage and transport from a disaster site."
Dr. Hogan also said the United States has little experience in terrorist bombings, and the lessons learned from bombings in foreign counties are often difficult to apply to a domestic response because of differences in the EMS system and medical care system.
CHEMICAL WARFARE AGENTS: EMERGENCY MEDICAL AND EMERGENCY PUBLIC HEALTH ISSUES
The article presents a compressive discussion of chemical warfare agents and discusses how communities must address both emergency medical and emergency public health issues in their preparedness and response activities. It outlines the risks of chemical warfare agents to civilian populations, presents an overview of agent classification and characteristics, and discusses issues in disaster preparedness -- education and training, disaster plans and exercises, public education, specialized response teams, and stockpiling antidotes -- as well as the principles of emergency response and medical treatment.
"The intentional or unintentional release of a chemical warfare agent in a community has the potential to create thousands of casualties, thereby overwhelming local health and medical resources, who presently are inadequately prepared to deal with a significant event" said Richard J. Brennan, MBBS, MPH, of the National Center for Environmental Health, Centers for Disease Control and Prevention. "Several programs are under way to expand the response capability at the local, state, and federal levels. But further efforts are required to appropriately train, equip, and update personnel who may be required to respond to chemical incidents. Regardless of whether civilian exposure to a chemical agent is the result of terrorism, a release from the military stockpile, or an industrial incident, coordination will be required among prehospital personnel, law enforcement, emergency physicians, public health specialists, toxicologists, laboratorians, environmental engineers, and security personn
PRINCIPLES FOR EMERGENCY RESPONSE TO BIOTERRORISM
The article discusses how a series of anthrax-related hoaxes illustrates the need to educate emergency personnel about how to best ensure patient and worker safety in cases of suspected exposure to biological threat agents. It also describes how emergency physicians, first responders, and hazardous materials response teams need a standardized approach to managing patients who may have been exposed. In addition, it discusses their need for a working knowledge of recommended isolation and infection control measures, as outlined in the CDC Guidelines for Isolation Precautions in Hospitals.
"Emergency physicians confronted with an alleged community-based biological agent exposure of persons should immediately notify an infectious disease consultant, the hospital laboratory officer, the local public health department, and appropriate law enforcement personnel," said Mark Keim, MD, of the National Center for Environmental Health, Centers for Disease Control and Prevention (CDC). "At a minimum, a second tier of notification, either directly or through local or state resources, should include the Federal Bureau of Investigation and the CDC."
During 1998 and early 1999, nearly 6,000 persons across the United States were affected by a series of anthrax-related threats. Emergency medical response included scene isolation, quarantine, hazardous materials decontamination of threat victims, emergency medical evaluation, chemoprophylaxis, and expert consultation. News reports have cited the estimated cost of one response at nearly one-half million dollars. These hoaxes also occupy time and effort of emergency responders.
"The challenge now confronting the discipline of emergency medicine is to educate emergency care providers regarding the safety and efficacy of treatment options, incorporating existing guidelines and regulations, and assimilating new knowledge as it becomes available," added Dr. Keim.
Editorial: Education is the Key to Defense Against Bioterrorism. The greatest threat to the United States and its citizens in the first decade of the 21st century will not come from a military confrontation, but from an attack within the borders, says Edward Eitzen, Jr., MD, MPH, Colonel, of the US Army Medical Corps. The editorial describes how biologic weapons pose perhaps the greatest threat and that the main defense against the massive casualties, panic, and disruption that biological agents, such as anthrax, plague, smallpox, tularemia, or botulinumtoxins, will be the astute emergency clinician with a high index of suspicion who spots a suggestive clinical or epidemiologic pattern in victims early on, and sounds the alarm.
Do U.S. Emergency Medicine Residency Programs Provide Adequate Training for Bioterrorism? A survey of emergency medicine residency programs found there is no standardized curriculum for training emergency physicians about the health hazards related to weapons of mass destruction. Opportunities for widespread teaching of this material have remained limited, and the range of knowledge regarding even general disaster medical care is variable among most residency training programs in the United States. The article says that future efforts should be directed at training and educating emergency physicians in residency programs and in hospitals.
Editorial: Chemical Incidents in the Emergency Department: If and When. Dr. Peter Pons of the Denver Health and Hospital Authority, Department of Emergency Medicine, addresses how the effort to educate the medical community about managing a victim of hazardous material contamination has received a lukewarm reception. The editorial discusses the need for emergency personnel to be trained in "syndrome recognition," the problems associated with identifying hazardous materials, and how the reality of emergency care stresses the need for readiness of emergency departments, not dependence on outside assistance.
Telecommunications Systems in Support of Disaster Medicine: Applications of Basic Information Pathways. The article explores various telecommunications tools for enhancing medical response in a disaster, including telemedicine. It describes how a lack of communication is one of the most serious problems experienced during a disaster, specifically the lack of appropriate means to efficiently collect, process, and transmit information in the midst of a disaster.
Editorial: The Medical Response to Modern Terrorism: Why the "Rules of Engagement" Have Changed. Saying the bombings of American embassies in Africa, New York's World Trade Center, and the federal building in Oklahoma City have served as a wakeup call for the United States, Dr. Marc Eckstein of the Los Angeles City Fire Department discusses how the realization that America is no longer immune to acts of terrorism has profound consequences for health care providers. The editorial discuss the need for a uniform approach to these incidents and how emergency responders, including law enforcement and EMS providers, are not only potential victims but potential targets.
Annals of Emergency Medicine is the peer-reviewed journal of the American College of Emergency Physicians, a national medical society representing more than 20,000 physicians who specialize in emergency medicine. ACEP is committed to improving the quality of emergency care through continuing education, research, and public education. Headquartered in Dallas, Texas, ACEP has 53 chapters representing each state, as well as Puerto Rico and the District of Columbia, and a Government Services Chapter representing emergency physicians employed by military branches and other government agencies.
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