In our series on Aum Shinrikyo we looked at both what happened in the response, specifically focused on the medical and emergency medical services, and offered some lessons learned.  As noted there were four main points of failure:

• Agent Identification
• Decontamination/Personnel Protection
• Medical System Response
• Psychological Casualties and the Worried Well

The Tokyo attack galvanized efforts around the world to counter and combat the CBRN threat. The majority of these efforts focused on agent identification and decontamination. As part of those efforts some agencies, individuals, and groups sensationalized the effects of CBRN for a variety of motivations including a desire for funding. Efforts to respond to the threat and exaggerations about the threat expanded after the events of September 11, 2001. These efforts missed some of the lessons of March 1995. While agent identification has seen dramatic improvement, decontamination is an unfinished task. The medical system and the problem of worried well and psychological casualties did not receive significant attention in part because those problems were seen as harder to solve and more resource intensive. Yet the example of St. Luke’s shows they need not be. Likewise, the exaggeration and subsequent events have decreased the credibility of government officials. Social media use has also expanded greatly. This suggests that worried well problems will likely grow larger in the future.

The key points of improvement needed are in the medical system, and where the emergency response services interface with the medical system. It is overdue for emergency operations planners and response personnel to stop considering the medical system as a destination to reach in a response, an end to the “response” phase, and place that aspect of the system where it belongs – as a critical part of the response, from the first minutes until after the scene clears. The locus of CBRN, mass casualty, disaster, and other major events is the medical system, not the incident scene or scenes.

This series of posts at CBRNPro.net sought to outline ways that CBRN response plans and first responders can conserve resources and recommended procedures that are relatively easy, low cost, and effective to implement. Most of these address concerns within the medical system. Some, like decontamination, cross agency, jurisdictional, and cultural boundaries. Coordination and communication is essential. No amount of planning can sufficiently replace the value of established relationships and day-to-day operating practices in an emergency. Further, some of these measures, like site control or medical capacity apply outside the realm of both CBRN and emergency planning.  Others, like the use of non-medical staff, are just good management practices.

On the decontamination and coordination front, the key points are:

• Siteaccess control: First step in the event of a CBRN event at any hospital or medical facility should be to “lock the doors” and establish control over all arriving patients to prevent contaminating the hospital, staff, or other patients.
• Gross decontamination: The principles are the same as those used by the fire department – dilution is the solution to all pollution. Both the fire hoses and hydrants are already available at many hospitals. Training, fog nozzles, and a procedure are the only missing elements. Additional procedures for dealing with casualty clothing and PPE for those meeting potentially contaminated casualties are important, but not vital in a pinch, as “field expedient” measures can replace such niceties. The goal is to have a decontamination plan that will work and is “good enough.” It need not be perfect. Any way casualties get from clothed to near naked and rinsed while not contaminating others is a functional solution.
• Coordination with the scene: The lack of communication between the TPD, TFD, EMS, and St. Luke’s was a constant problem. This problem is not a rarity in other jurisdictions. Hospitals and medical facilities like urgent care clinics must be “in the loop” for all disaster planning, but especially for CBRN incidents. A CBRN response plan that does not address this issue is not adequate. As noted, addressing this issue in day-to-day operations is already an imperative in some jurisdictions. The more that this can be worked into regular operations the better it will work in a CBRN event.  

Then there is the problem of psychological casualties and the “worried well.” These are a known issue in most CBRN events and one that should not be ignored. The key factor in dealing with the issues surrounding psychological casualties and the worried well is keeping them away from key medical installations in the first place, and if that fails, redirecting them to alternate sites. The key elements for such a system are:

• Public Information: Information must be timely, credible, and factual. Public information strategies should learn from the communications problems experienced most acutely during the response to the 2001 Anthrax Attacks and implement those solutions, in addition to having robust social media strategies which threaten to overwhelm any official news sources and spread rumors and false information, as evidenced in the Boston bombers case.
• Low Risk Patient Response Plan:  Originally outlined by Fred P. Stone in 2007, his plan focuses on encouraging the worried well to either stay home (through public information) or redirects them to alternate facilities for assistance during high demand periods for health care facilities in CBRN events.  CBRNPro.net added the suggestion that mental health professionals and “magic box” screening can also be used at these alternate facilities, as well as using these sites to recruit for volunteers. The ability for individuals to feel like they are “doing something” not only reduces worried well, it can be a contributing factor in reducing incidents of psychological problems like PTSD. Finally, gateway screening at secured medical facilities can be used to deal with low risk patients who fail to redirect or stay home.
• Expansion capacity and communication: Hospitals and jurisdictions must plan and coordinate their plans to account for large, sudden surges in demand for patient care. The use of non-medical staff and volunteers to relieve medical staff of non-medical related duties is one potential strategy. Further, medical facilities, emergency management officials, and responders must have a solid communications plan that allows for the timely dissemination of information amongst each other, with their personnel, and with the public. These communication channels should mirror those of normal everyday communication networks to the maximum degree possible, even in cases where that requires establishing and maintaining a new network.

As Aum Shinrikyo and more recent events show, the “weak link” in emergency management is typically the medical system. CBRN events like the Tokyo attack, demonstrate that the medical system is the locus for CBRN response, maybe even more so than the incident scene.  St. Luke’s example in 1995 proves that hospitals will struggle as much as any service in response, but they need not be the weak link. The Aum Shinrikyo attack shows that CBRN response is not a great monster come to swallow us all. Rather, dealing with the issues of CBRN response requires only a little planning and adaptation of existing practice, which does not cost piles of money. St. Luke’s and Tokyo did not respond well to the Sarin attacks initially, but they quickly adapted and given the circumstances, especially at St. Luke’s, did about as good as could be expected.

It is possible however, to do much better, with only minor tweaks to existing plans, procedures, and techniques, all of which have wider application to more general mass casualty events and public health emergencies like disease outbreaks (the recent Ebola scares being only one example). The solution does not require extensive new plans, spending lots of money, or purchasing equipment. Rather, the solution to the issues that the Aum Shinrikyo case highlighted is simple – better communication and a few tweaks to existing operating practices. That and remembering, when in doubt, keep calm and decon.