Are you prepared for terrorist attack? New report tells how to train ED staff

Experts: Many EDs have almost no preparation’ to treat victims

Would you be able to identify an outbreak of smallpox that was a result of a biological terrorist attack — before it spread throughout your community? Could your ED decontaminate dozens of people if a chemical spill occurred in your city? Does your staff know how to protect themselves to avoid being injured by contaminated patients?

If you answered "no" to these questions, you’re not adequately prepared for a nuclear, biological, or chemical (NBC) incident, according to Robert Schafermeyer, MD, FACEP, president of the Dallas-based American College of Emergency Physicians (ACEP) and associate chair for the department of emergency medicine at Carolinas Medical Center in Charlotte, NC.

A new report from ACEP and the Department of Health and Human Services’ (HHS) Office of Emergency Preparedness gives you a "benchmark" to prepare ED staff for NBC incidents, with specific training objectives. (See "Resources," at the end of this article, for information on obtaining the complete report.) "This is the first comprehensive report on training for ED physicians, nurses, and the EMS community," explains Schafermeyer. Performance objectives include event recognition, safety and protection, decontamination, triage, and treatment.

You should be familiar with the report’s recommendations to prepare for NBC incidents, he urges. "ED managers will be the ones to initiate training across America, so communities can respond effectively to these kinds of disasters," says Schafermeyer. The potential number of casualties from a biological attack may be staggering, he warns. "In fact, an attack on a major city could approximate the lethality of a small nuclear explosion," Schafermeyer says. "Only if victims can be identified and treated quickly can the number of deaths be decreased."

Unfortunately, most EDs are still poorly prepared for NBC incidents, stresses Robert Suter, DO, MHA, FACEP, senior medical director for Questcare Emergency Services, a 13-hospital group serving the Dallas-Fort Worth area. "The most common misconception is that it’s impossible to prepare for these events," he says. "You absolutely can." You’ll need to make sure your training programs incorporate the information in the report, says Suter. "Just by reading the report, you will be stimulated with ideas to update or correct your disaster plans," he adds.

Some EDs have almost no preparation at all for decontamination on a large scale, reports Schafermeyer. "Although some hospitals have treated victims of chemical exposure, very few are prepared to treat 40, 100, or several thousand patients from a terrorist attack in a congested urban area," he notes. Even fewer are prepared for biological terrorism, especially if the number of victims is extensive, says Schafermeyer. (For more information about preparation for terrorist attacks, see ED Management, November 1999, p. 121.)

Here are ways to comply with the report’s objectives and improve preparedness:

• Include instructions for NBC incidents in your disaster plan.

Suter advises addressing NBC incidents within your overall disaster plan, with "add-ons" for these specific scenarios. "The process of dealing with NBC events is identical to others, with the exception of personal protective equipment, decontamination equipment, and antidotes," he explains. (To see Code Yellow Institutional Disaster Plan, click here.)

• Make sure that staff practice decontamination.

Disaster drills need to include a decontamination scenario, advises Robert Takla, MD, FACEP, medical director of emergency services at St. John NorthEast Community Hospital in Detroit. "The situations often pose unique, inherent challenges that do not pertain to other disasters, such as the establishment of a decontamination reduction zone and a buffer zone, and their proper use," he says.

Recently, the ED held a drill with patients contaminated by organophosphate, with Takla notified of the approximate time so he could be available. "As soon as we got the call, we called the code, set up our decontamination tent, donned the proper equipment, and began," he says.

Putting on the protective gear and practicing decontamination procedures helped staff a lot, says Takla. "ED personnel learned to don the personal protective equipment faster and more easily. We did have one security person step into the hot zone, and subsequently he became contaminated and a patient himself."

Stepping back to protect yourself with use of personal protective equipment is difficult to do under pressure, notes Takla. "It is contrary to the habit of working under the premise that seconds count," he notes. Takla acknowledges that a real disaster will be much more chaotic, challenging, and unpredictable than any drill. "Nevertheless, every drill is a practice session, and we learn something valuable each time," he says. "We work better as an effective, cohesive team each time we practice, and that is very important when responsibility is delegated out as in a mass casualty situation."

• Be realistic when developing strategies.

Avoid impractical strategies with difficult or costly requirements, advises William Dalsey, MD, MBA, FACEP, an ED physician at Robert Wood Johnson University Hospital in New Brunswick, NJ. "For example, many EDs would be well-served by using the fire department pumper trucks to provide water for decontamination of large numbers of patients," he notes.

• Have staff trained immediately.

Courses that specifically address the objectives in the report are being developed, reports Schafermeyer. "It’s possible that a curriculum could be available next year," he says.

Until the planned courses are available, have an instructor trained by the Department of Defense or who has undergone training in hazardous materials provide appropriate inservices and continuing education, Suter recommends. "A good source of information on finding local experts and instructors is your local fire department," he notes. Accept the fact that this training will take more than a few hours, usually several days, and plan accordingly, Suter says. "The report states that the primary obstacles to training are funding and time constraints," he notes.

• Prevent secondary contamination.

Most EDs are unprepared to decontaminate large numbers of patients, according to Dalsey. (See Excerpt from HazMat Patient Decontamination Response Plan, in this issue.)

In hazardous material or weapons-of-mass-destruction incidents, all patients must first go through the decontamination reduction zone to be decontaminated properly before being allowed to enter the ED, says Takla. All medical personnel must protect themselves and other patients from potential exposure to hazardous substances, before providing initial care to contaminated patients, urges Takla. "This is not the usual patient encounter most ED health providers are used to," he says. If these protocols are not followed, the health provider may become a contaminated patient and possibly could contaminate others in the process, Takla warns.

Dalsey adds, "Practicing the plan, so that everyone follows the protocols that provide for decontamination, clean areas, and use of personal protective gear, can help avoid such incidents."


For more information about disaster planning, contact:

William Dalsey, MD, MBA, FACEP, Robert Wood Johnson University Hospital, 1 Robert Wood Johnson Place, New Brunswick, NJ 08903. Telephone: (732) 937-8944. Fax: (732) 828-3000. E-mail:

Robert Suter, DO, MHA, FACEP, Questcare Emergency Services, 101 E. Park Blvd., Suite 921, Plano, TX 75075. Telephone: (972) 881-8353. Fax: (972) 422-2208. E-mail:

Robert Takla, MD, FACEP, Emergency Services, St. John NorthEast Community Hospital, 4777 E. Outer Drive, Detroit, MI 48234-3281. Telephone: (313) 369-5689. Fax: (313) 369-5582. E-mail:

The full report Developing Objectives, Content, and Competencies for the Training of Emergency Medical Technicians, Emergency Physicians, and Emergency Nurses to Care for Casualties Resulting From Nuclear, Biological, or Chemical (NBC) Incidents from the American College of Emergency Physicians and the Office of Emergency Preparedness can be downloaded free of charge at ACEP’s web site ( Click consecutively on "EM Practice," "EMS," and "NBC Final Report." Or to order a free copy, contact:

Matthew Payne, Office of Emergency Preparedness, 12300 Twinbrook Parkway, Suite 360, Rockville, MD 20852. Telephone: (301) 443-3115. Fax: (301) 443-5146. E-mail: