An approach to terrorism preparedness: Parkland Health and Hospital System

In response to growing concerns regarding domestic terrorism, the 104th Congress passed Public Law 104-201, the National Defense Authorization Act, for fiscal year 1997. In addition to providing the nation's first responders (i.e., law enforcement agencies, fire departments, emergency medical services, emergency planners, and health care personnel) with training regarding emergency response to weapons of mass effect (WME), this legislation required that the secretary of defense develop and carry out a program for testing and improving the responses of federal, state, and local agencies to emergencies involving nuclear, biological, and chemical weapons. Federal officials determined that the first phase of this ambitious nationwide effort, known as the Domestic Preparedness Program, be concentrated in the most highly populated metropolitan areas in the USA. As such, the 120 most populated cities in the country were initially identified to receive the planning, training, and evaluative efforts of the program.

As the eighth largest population center in the USA, the city of Dallas underwent the Domestic Preparedness Program's communitywide analysis in the fall of 1997. This analysis included the resources, strengths, and shortfalls within the existing municipal services and medical community. A multidisciplinary team with representation from the areas of law enforcement (Dallas Police Department, Dallas division of the Federal Bureau of Investigation [FBI]), fire suppression and emergency medical services (Dallas Fire Department), city administration (Office of Emergency Preparedness, Department of Water and Streets), and the medical community (City of Dallas Environmental and Health Services, Dallas County Medical Examiner, Dallas County Health and Human Services, The University of Texas Southwestern Medical Center [UTSW], Parkland Health and Hospital System [PHHS]) was assembled to plan, develop, and test a citywide preparedness plan.

The development of the Dallas Metropolitan Medical Response System has taken place over a 48-month period, from July 1997 to July 2001. This process involved the cooperation and planning of over a dozen government and community agencies. Throughout this period, PHHS, in concert with the Dallas-Fort Worth Hospital Council, has actively participated in the development and implementation of medical community education and hospital facility preparations specific to these events. Despite the absence of a dedicated funding stream to defray the costs of personnel, education, medical supplies, and pharmaceuticals, PHHS has been recognized as a national model for hospital preparedness efforts. A comprehensive document entitled Nuclear, Biological, Chemical Readiness Guidelines, published in September 2000, details the hospital's efforts.

DEFINING THE PROBLEM

First, PHHS officials sought to redefine and reevaluate the catchment area of its patient population and communities of interest. This evaluation focused on the unique threats of terrorism and led to the realization that the following vulnerabilities and potential targets reside within the PHHS catchment area: north central Texas is a significant population center (5.1 million people, 20% of the population of Texas); Dallas County (880 square miles, 2 million population) is a geographically large, complex county containing the city of Dallas and 22 other suburban cities; and Dallas-Fort Worth is an extensive transportation hub (rail, air, motor freight). Moreover, the region also is home to the Comanche Peak nuclear power facility; Interstate 20, which serves as the major east-west corridor for the Waste Isolation Pilot Project; multiple federal, state, and city offices; and multiple large-venue attractions (amusement parks, sports facilities, convention complexes).

Next, PHHS evaluated the medical community and acknowledged both its role as a significant medical resource and its obligation to protect and preserve the health and well-being of the community in the event of a terrorist incident. Resources unique to PHHS that may assist in the mitigation of a terrorist event include the 940-bed county hospital; 7 community-based health clinics in addition to school-based and mobile clinics; the level I trauma and burn center; BioTel, a unified emergency medical system medical command and hospital notification center; North Texas Poison Control Center; and affiliations with UTSW and its allied health sciences school.

Following this assessment of vulnerability and resources, PHHS officials elected to devote personnel, time, and resources to develop, train, and periodically test and revise the hospital's plan for response to a terrorist event. Representatives from the departments of safety management, emergency services, infection control, pharmacy, facilities maintenance, bioengineering, and education formed a multidisciplinary team to lead this effort. The group's first task was to modify the hospital's existing disaster plan to address the unique nuances of a response to a chemical, biological, or nuclear agent exposure. Professionals from a variety of departments within PHHS and UTSW reviewed and revised disaster plans relative to these specific agents. The departments of radiology and environmental health and safety revised plans involving radioactive agents; the departments of infection control and infectious diseases revised response protocols for biological agent exposure; and emergency services, emergency medicine, and the North Texas Poison Control Center revised chemical agent exposure protocols. Key contacts, lines of communications, and treatment/isolation protocols were developed to expedite the identification, treatment, and surveillance of exposed individuals.

DEFINING CRITICAL FUNCTIONS

In addition to updating PHHS's disaster plans, the multidisciplinary team also identified 5 critical functions for event mitigation: safety and security, decontamination, acute and definitive medical care, communications, and resource procurement and management. The activities and actions necessary in these critical functions are described briefly here. These functions may be applicable in whole or in part, depending upon the agent utilized in the terrorist attack.

Safety and security

Since terrorists may identify health care facilities as primary or secondary targets, safety and security issues are important. Confusion and fear will be prominent among civilians, regardless of their actual involvement in the incident. This will bring unprecedented numbers of victims, concerned family members, and “worried well” to hospitals. In a WME incident, safety personnel should establish a secure perimeter around the hospital campus, controlling access to vehicle and foot traffic. This will simultaneously limit access by criminal elements and prevent contamination by the uncontrolled arrival of victims. Separate patient and employee entrances should be secured and maintained throughout the event, and a system of identification should be in place allowing hospital access to “critical-need” employees only.

Since the use of a WME is a criminal act, key information should be collected from victims. A scripted interrogation should include the time and location of the event, an estimate of the number of people involved, any unusual activities or people noticed just prior to the event, and any unusual sights, sounds, or smells just after it. Documentation of the prominent signs and symptoms experienced by those who have been exposed may aid in the early identification of the agent involved. Evidence collection (e.g., bagging of clothing samples) from victims prior to decontamination may yield clues as to the nature of the agent. Interrogation and evidence collection activities should be coordinated with local police and FBI officials. Regular security sweeps of the hospital facility should be performed looking for secondary devices, unauthorized personnel, or breaches in building access.

Decontamination

To prevent contamination and subsequent closure of the hospital facility and to ensure the safety of personnel and currently hospitalized patients, victims of nuclear or chemical attacks will usually be triaged and undergo decontamination at a central location external to the facility. (Decontamination is rarely if ever necessary for biological agent exposure.) While decontamination activities do not require medically trained personnel, the process is overseen by medical providers who perform triage and provide stabilizing, rudimentary care as needed. Specific hospital personnel should be trained to perform decontamination activities while in appropriate personal protective equipment.

The utilization of specific decontamination techniques as it relates to individual agents (nuclear, chemical) should be based upon a combination of information from law enforcement or on-scene intelligence and medical expertise. Personnel should be able to perform gross decontamination of nonambulatory and ambulatory patients. Decontamination solutions and containment of runoff should be consistent with the community response plan and in accordance with the local water and sewer policies. Specific logistical issues should be clearly defined in the hospital response plan. This should include a system to identify and bag personal effects (valuables), tag and bag clothing (potential evidence in a WME event), and provide gender-specific changing and decontamination corridors and modesty garb. These issues should be addressed before the patient enters the health care facility for medical treatment. A unified, strong presence from the security/safety organization will promote cooperation and efficiency in accomplishing mass decontamination.

Acute and definitive medical care

Hospital personnel should be available to respond to a mass casualty incident on an “as-needed” basis. As established in the response plan, a roster system for mobilizing adequate numbers and types of manpower should be utilized. Acute care physicians and nurses (emergency medicine, surgeons, intensivists) will be most useful in addressing anticipated injuries and illnesses (traumatic injury, respiratory extremis, toxidromes). Infectious disease physicians should be consulted for any infection suspected to be related to a biological attack. Allied health staffing should include operating room support staff, radiology, clinical laboratory services, pharmacology, infection control, and respiratory therapy. Because the results of laboratory assays and foreign material removed from victims may be potential evidence, medical personnel should understand that cooperation with local law enforcement and FBI officials is critical for evidence collection and the eventual prosecution of the perpetrators of these incidents.

Hospitals may develop a defined treatment policy (for victims and currently hospitalized patients) based upon their resource capabilities. Facilities should decide if they will perform both acute and definitive victim care or acute care only with the transfer of victims to specialized facilities distant from the local incident. Hospitals may choose to accept no acute victims and instead accept transfers of stable, hospitalized patients from other facilities to free up bed capacity for victims. Patient treatment and mobilization agreements must be clearly defined by contract and response plans between hospital agencies. Preplanned access to ancillary, off-site facilities (e.g., schools, hotels, public halls) may expand the capacity of a hospital; such facilities may be utilized to perform short-term observation for masses of asymptomatic victims.

Communications

An organized and regimented system for external and internal communication is an important component of any disaster plan. External communications issues include the need to exchange information with local emergency management agencies and other heath care facilities; disseminate standardized, nonsensational information sound bites for the local news media; act as a clearinghouse for victim identification and condition; and act as a public information source (public service announcements) about event-related issues (e.g., signs/symptoms, where to obtain medical care). Internal communications involve the need to communicate with employees concerning the nature of the event; implement the hospital disaster plan; activate the staff “call back” and rotation system to ensure adequate manpower; and provide critical incident stress debriefing for both personnel and their families.

Resource procurement and management

Knowing the particular agent (chemical, biological, nuclear) and route of exposure (inhalation, ingestion, contact), hospitals may anticipate an increased need for specific facilities, supplies, equipment, and medical expertise. The hospital response plan should include prearranged agreements with local industry/agencies, vendors, and other health care facilities for resupply and exchange of resources in the event of a WME attack.

Hospital resources may be conveniently divided into the following groups: facilities, supplies and pharmaceuticals (single-use items), equipment (multiple-use items), and manpower.

Facilities for the treatment and/or observation of victims may include traditional hospital settings or off-site ancillary settings. Nontraditional settings may include schools, meeting halls, and hotels. Specific areas of the hospital or external, contiguous locations should be designated for activities such as triage, decontamination, biological isolation, and short-term observation. Current physical plant facilities or rapidly deployable temporary facilities may be useful in managing large numbers of victims.

Because medical supplies, especially single-use items such as personal protective equipment, pharmaceuticals, antiseptics, and cleaners, will be in high demand, preemptive stockpiling of frequently used items may be helpful. Pharmaceutical companies, medical supply vendors, and hospital exchange contracts may allow for emergency reordering when demand is increased. Bulk reconstitution of specific pharmaceuticals or access to military stockpiles are other options that can prevent pharmaceutical shortfalls when large numbers of victims require treatment. Prearranged contracts and agreements with vendors and nearby military facilities may allow for an uninterrupted supply of medical care items.

Equipment that may be needed in increased numbers includes mechanical ventilators or respiratory assist devices, cardiac monitors, and portable radiography units. Hospitals must choose between prearranged contracts for procuring additional equipment or transferring victims to other hospital locations within nearby states or regions that have surplus equipment.

Medical personnel within the hospital may be trained and designated to respond to WME events. Personnel with key roles include, but are not limited to, physicians, nurses, respiratory and radiology technicians, safety and security officers, administrators, and public relations officers.

It should be recognized that ensuring the safety and security of the families of medical personnel may assume a high priority, since this may prevent hospital personnel from reporting for duty. Conservatively, it may be expected that 30% to 60% of hospital personnel may not report for work during an event. This loss of manpower may be experienced in the face of overload situations and extended operations.

Staffing shortfalls should be anticipated, and a “call back” or “rotating roster” system may be devised to ensure adequate numbers of personnel. Mechanisms to preemptively credential staff from the community (retired health care workers, students within the medical and allied health care fields), service agencies (American Red Cross, Salvation Army, visiting nurse agencies), other hospitals (those within geographic proximity or a multifacility health care network), and government agencies (National Disaster Medical Services) should be developed and operationalized.

DEVELOPING WME PROCEDURES AND DEPARTMENT-SPECIFIC RESPONSES

PHHS has charged key departments with specific roles and responsibilities relative to these 5 critical functions. These departments are emergency services, infection control, security and public safety, public relations and media, and pharmacy.

Emergency services personnel will likely make the first determination that a terrorist use of an agent has occurred. Knowledge of the general classes of agents, including their specific toxidromes, unusual clinical signs and symptoms, or unusual clusters of patients exhibiting similar signs and symptoms, should serve to alert clinicians to a potential event. Notification of hospital administration and a determination of the potential for disease spread must be made expeditiously. Triage and the need for decontamination or isolation are important early considerations. Emergency services personnel must maintain current knowledge of the initial stabilization and treatment of patients who have been exposed to the most likely chemical, biological, or radiologic agents. Data gathering on countywide hospital capacity, emergency transportation resources, hospital destination, hospital prearrival notification, and medical direction is one of the extremely important roles filled by BioTel, which resides within the Department of Emergency Services. Communications relative to area hospital capacity, patient destinations, and transport needs will be performed in cooperation with the joint information center within the City of Dallas Emergency Operations Center.

Infection control personnel are important in biological agent identification and may define and operationalize patient isolation needs. Epidemiologic principles should be used to detect the attack rate, source, and likely agent in cooperation with public health officials. Hospital isolation capacity, cohorting, and off-site observation facilities may require expansion. The facilitation of laboratory surveillance and testing are also key functions. Specific identification, isolation, and treatment protocols have been developed for the 4 biological agents considered most likely to be used by terrorists.

Security and public safety personnel may secure the hospital perimeter and limit facility access during an event. The maintenance of internal order and periodic security sweeps may be necessary to prevent unauthorized personnel from entering the facility. Ongoing interface with local and federal law enforcement agencies will promote complementary activities involving intelligence gathering, evidence collection, and investigative activities. The external decontamination facility is operated through the Department of Security and Public Safety with specially trained personnel. Members of the decontamination team drill periodically to maintain the requisite cognitive and psychomotor skills.

Public relations and media personnel may preemptively develop communications networks with local officials. Knowledgeable, predesignated spokespersons will schedule the delivery of timely, simple, accurate sound bites. As much as possible, the nature and detail of such media releases will be determined in advance. Communications will be performed in cooperation with the joint information center within the City of Dallas Emergency Operations Center. Public service announcements may report what has happened, signs and symptoms of exposure, appropriate self-care options, medical care options, and victim location assistance. Specific instructions on where victims should go to obtain triage and treatment, perhaps at novel locations, may lessen hospital burden. Coordination of specific announcements from all medical facilities is a critical component to ensuring that a uniform message is delivered to the public.

Pharmacy personnel have preemptively determined the potential agents of exposure, the most efficient and effective treatment options, the duration of therapy, and prophylaxis and vaccination needs and anticipated the potential numbers of victims. Review of the current treatment standards and available generic equivalents will determine the most cost-effective manner for treating large numbers of exposed or infected individuals. The Pharmacy and Therapeutics Committee will regularly review these policies to ensure medical validity and currency with the standard of care. A cache of pharmaceuticals and pars (amounts) will be kept on hand for immediate use. Purchasing plans, funding streams, and inventory maintenance and control have been determined in advance. Additionally, a use and distribution plan, storage location, and restock mechanism are the responsibility of pharmacy personnel. Preemptive external agreements with drug wholesalers and companies will allow rapid resupply and limit pharmaceutical shortfall when large numbers of individuals require expedient treatment.

SUMMARY

In Dallas, as in most metropolitan areas, the medical community is exceedingly complex. The health care community is fractionated into a bewildering array of providers including, among others, physician offices, clinics, urgent care centers, public health agencies, nursing agencies, and, of course, hospitals. In addition, the hospital community comprises a multitude of private and public facilities providing a range of services including basic medical/surgical care, acute/tertiary care, or special population (e.g., children, veterans) services. Such diversity and fractionation may act as a barrier in efforts to unify and organize the medical community's approach to WME events. Tenuous economics, competitive postures, and the absence of a single, controlling health care authority further dilute the medical community's sense of ownership and responsibility as it pertains to the management and mitigation of a WME event.

An analysis of the Dallas medical community revealed that there are 25 acute care hospitals with approximately 6300 beds (1999 American Hospital Association Guide, hospital listings). Less than 15% of hospitals within the greater Dallas-Fort Worth area have incorporated WME-specific planning, training, and treatment policies into facility disaster plans (Dallas-Fort Worth Hospital Council hospital survey, 1999). City planners, public health officials, and health care administrators have not developed a comprehensive, communitywide medical response plan. Such a plan should incorporate the resources of all facilities within the medical community. The entire medical community must commit to organized, widespread preparative efforts. As a public service and health resource, hospitals should acknowledge their responsibility to minimize morbidity and mortality within the community in which they reside. Hospital administrators and decision makers must prepare their facilities for the pivotal role they will play in the stabilization and treatment of victims, who may number in the thousands. Individual hospital characteristics, such as bed capacity, complexity of medical services, workforce sophistication, and mutual aid/contractual agreements, may be utilized to define the roles and responsibilities of specific facilities within the context of a WME event. If preparative efforts are not widespread and comprehensive, a single institution working in isolation will not significantly reduce community morbidity and mortality in the event of a WME incident.

--KATHY J. RINNERT, MD, MPH
Assistant Professor of Emergency Medicine
The University of Texas Southwestern Medical Center at Dallas

Efforts of the Dallas-Fort Worth Hospital Council to prepare for bioterrorism

Once the stuff of science fiction and disaster movies, the possibility of a terrorist attack against the USA using biological weapons is a grim reality as we enter the 21st century. Four years ago, terrorists unleashed sarin nerve gas on commuters in the Tokyo subway. More recently there has been a rash of anthrax hoaxes in the Los Angeles area. Intelligence experts and government officials, including President Clinton, have said it is a question of “when” not “if” a bioterrorist attack occurs. Discussing the possibility of a terrorist attack in the next few years, President Clinton has unequivocally stated, “This is not a cause for panic. It is cause for serious, deliberate, disciplined, long-term concern.”

A global threat assessment issued in December 2000 by the National Intelligence Council stated that the risk of a missile attack against the USA involving chemical, biological, or nuclear warheads is greater today than during most of the Cold War and will continue to grow in the next 15 years. The report also concluded that terrorist attacks against the USA through 2015 “will become increasingly sophisticated and designed to achieve mass casualties.” The most immediate threat comes from attacks using the weapons of mass destruction, such as chemical or biological weapons.

In the earlier days of the Cold War, civil defense was at the forefront of the nation's consciousness. Public buildings were designated fallout shelters, and school children practiced “duck-and-cover” drills in the event of a nuclear attack from the former Soviet Union. According to a study reported last year in the Journal of the American Medical Association (JAMA), hospitals and other health care facilities today are “poorly prepared” to handle a possible chemical or biological attack against civilian populations in the USA. The JAMA study researchers examined key elements of effective hospital response, including decontamination and triage, medical therapy, and coordination with public health agencies and emergency response personnel.

HOSPITALS ON THE FRONTLINE

In contrast to conventional disasters, biological and chemical attacks shift a large portion of the burden away from police and firefighters to hospitals and health care workers. Such an attack is revealed when large numbers of people who are violently ill arrive at emergency rooms. Experts agree that the US public health and medical systems are not well prepared to rapidly detect and contain the spread of anthrax, smallpox, plague, or the dozens of other possible agents not commonly seen by health professionals.

Jeffrey Koplan, MD, director of the US Centers for Disease Control and Prevention (CDC), has said, “A key issue is early detection. But our public health community's [monitoring] system has lagged that of many other sectors.” In an effort to improve the system, over the last 2 years Congress has appropriated >$275 million to the CDC for bioterrorism detection and response.

LOCAL EFFORTS TO PREPARE

The Dallas-Fort Worth Hospital Council has taken the lead in addressing our community's preparedness in what is now seen as the real possibility of a bioterrorist attack. Early last year, a core planning committee was established with approximately 30 officials from numerous local entities, including police and fire departments, departments of health, the poison control center, and hospitals, to develop a collaborative response plan for the Dallas-Fort Worth metroplex.

The goals of the committee, led by Ron Anderson, MD, of Parkland Memorial Hospital, were to understand the threat and potential impact of such an emergency on the community and to establish systems allowing medical facilities to share information, coordinate and identify needs, and manage patient load.

The first step taken by the committee was to survey hospitals in the Dallas-Fort Worth metroplex to determine their capabilities. The survey found that there are 970 intensive care unit beds, 1055 emergency department beds, and 800 ventilators available to treat victims of a bioterrorist attack. Of the 58 medical facilities that responded to the survey, 36 have the facilities to decontaminate patients who have been exposed to chemical or biological weapons. Assuming all of these facilities were operational and available, 1300 victims per hour could potentially be decontaminated.

The next step in the response planning process was the development of a comprehensive list of personnel who could assist in an emergency. Because the response is not limited to Dallas-Fort Worth, the list includes the Federal Bureau of Investigation (FBI), the Department of Health, the Department of Defense, and the Environmental Protection Agency, as well as local agencies such as fire and police departments. Within 48 hours of an attack, the federal government is expected to bring in medications that may not be immediately available locally. Officials from the state government would manage civilian population issues like temporary housing or transportation.

A REAL-TIME COMMUNICATION LINK

According to John Gavras, executive director of the Dallas-Fort Worth Hospital Council, a critical component in ensuring a well-coordinated response to a bioterrorist attack is an effective communication system. An integral part of the work of the Dallas-Fort Worth Hospital Council is the development of a communication system, possibly Internet-based, to allow for real-time information exchange between hospitals and all other emergency responders.

Unlike conventional disasters, such as a plane crash or bus accident, victims of a bioterrorist attack must be evaluated prior to allowing a massive influx of contaminated patients into the hospitals. The experiences of Japan and other places tell us that with a biological or chemical weapon attack, people do not call 911. They drive their cars to emergency rooms. Realistically, the first few facilities receiving these contaminated patients must lock their doors to prevent spread of contamination. But once an attack has been identified, communication throughout the public health system can contain its spread and allow the remaining facilities to prepare. Additionally, the need for certain medications or antidotes can be quickly identified and disseminated.

A strong communication link also would enable the health care system to provide better care on an everyday basis. Consider, for instance, the struggles hospitals face during flu season. Emergency departments often are overflowing with patients. An integrated communication system would enable us to manage patient loads by instantly sharing information among hospitals about capacity. Ambulance drivers could be diverted to facilities that have available beds. This could make a major difference to the elderly patient who needs a critical care bed but may have to wait in the emergency department.

While the communication system is not yet complete, the Dallas-Fort Worth Hospital Council has received praise from many government agencies, including the FBI, which says it will use the council's system as a model for its regional offices throughout the USA. Dallas-Fort Worth is thought to be the first community in the nation to start an emergency communication system of this kind.

A CONTINUING FOCUS ON READINESS

According to the American Hospital Association, about 25% of hospitals are currently at some state of readiness for a chemical or biological incident. While it is difficult to know how to measure our current state of preparedness, we do know Dallas-Fort Worth is better prepared than it was 1 year ago. As health care providers, we must never become lax. The Oklahoma City bombing reminded us that a disaster can happen anywhere. We must continue to sharpen our preparedness for whatever the new century may bring.

--TIM PARRIS
President, Baylor University Medical Center

Originally published as “Are we prepared to counter weapons of mass destruction?” in Texas Healthcare Metroplex. Reprinted with permission.

Emergency department preparedness at Baylor University Medical Center

A number of studies have reported that emergency departments are poorly prepared for bioterrorism events (1-3). In fact, bioterrorism attacks with agents that produce subtle gastrointestinal or constitutional symptoms may be hard to detect. In a given night or over the course of days to weeks, a number of patients could present to emergency departments across the city with similar symptoms caused by exposure to a biological agent and be diagnosed with the flu or some other nonspecific illn

ess. It could take days to determine the cause of the illness, since no organized system exists for tracking cases of suspected biological agent exposure. Even when systems for tracking diseases are available, such as the Foodborne Disease Active Surveillance Network (FoodNet) of the Centers for Disease Control and Prevention, some studies indicate that only a fraction of suspected food poisoning cases are reported (2).

When the cause of the attack is obvious, as with the sarin attack in Tokyo, the problem for emergency departments becomes mobilizing limited resources to treat victims as well as the multitude of nonexposed citizens caught up in the inevitable mass hysteria produced by such an event. During the Tokyo incident, 11 people died and >5000 people sought care in local emergency departments. Seventy-four percent of those patients had no identifiable injuries or exposure. One hospital triaged 641 patients in a day (our emergency department sees an average of 220 patients a day). Historically, the federal government has emphasized bioterrorism preparedness in first responders, such as emergency medical services and police departments, despite the fact that most patients will eventually present in the emergency department for care. More recently, however, the emergency department is being recognized as a critical component in any response plan. For example, the American College of Emergency Physicians has received a federal grant to develop curricula to prepare emergency physicians, nurses, and technicians to respond to episodes of terrorism in which weapons of mass destruction are used.

The bottom line is that emergency medical personnel must maintain a high degree of suspicion for biological terrorism when numerous patients present with similar, unexplained symptoms, and emergency medical systems must be able to properly distribute resources to provide the best care for the large number of patients that will be seen should an attack occur.

If all emergency departments and their staffs need to be aware of the unique problems associated with biological agents, this is particularly true of level I trauma centers, such as Baylor University Medical Center (BUMC). Preparation for bioterrorist attacks includes both modification of the physical plant as well as staff awareness and training. The first goal was accomplished with the addition of a formal decontamination room during the last renovation of the department in 1998. Patients coming to the emergency department from a scene where biological agents are released must be assumed to have contaminated skin and clothing. Failure to remove contaminants before patients enter the hospital can spread the toxic effects to the staff. In the Tokyo sarin attack, 20% of the hospital staff treating the victims was contaminated. The BUMC decontamination room is equipped with a shower and hose that were recently modified to supply warm water. Should mass decontamination be required, a 75-foot hose is now available to provide decontamination on the ambulance dock before patients enter the department. In addition, the ventilation system in the room generates negative pressure, with the air being exchanged 27 times an hour. The floor was designed to be impervious to chemicals, and the water from the hose is drained into a container under the floor for later disposal.

Personal protective equipment, such as chemical suits and self-contained breathing apparatus suits, are available for staff participating in decontamination, and in-service training is offered in the department about their proper use. In addition, bioterrorism scenarios have been included in the BUMC biannual disaster drills mandated by the Joint Commission on Accreditation of Healthcare Organizations. In August 2000, members of the emergency department staff also participated in a bioterrorism drill conducted by the National Disaster Medical System.

Any disaster, man-made or natural, places sudden, often unique demands on the emergency department and ultimately the hospital, including the entire medical and ancillary staff. Only through careful planning and training of staff can optimal patient care be delivered when needed. The emergency department at BUMC continues to pursue strategies to maintain awareness so that a high level of care can be delivered should such an attack ever occur in the Dallas area.

--JOSEPH ZIBULEWSKY, MD, AND NANCY ARQUIETTE, RN
Department of Emergency Medicine
Baylor University Medical Center

1. Macintyre AG, Christopher GW, Eitzen E, Gum R, Weir S, DeAtley C, Tonat K, Barbera JA. Weapons of mass destruction events with contaminated casualties: effective planning for health care facilities. JAMA 2000;283:242-249.
2. Pesik N, Keim M, Sampson TR. Do US emergency medicine residency programs provide adequate training for bioterrorism? Ann Emerg Med 1999;34:173-176.
3. Eastman P. US unprepared for bioterrorism, expert warns. Emergency Medical News 1998;July:36-38.

Bioterrorism--a prospect for Dallas?

And he that will not apply new remedies must expect new evils; for time is the greatest innovator. --Sir Francis Bacon, Essays, 1601

How many cases of smallpox have you seen? How many cases of pulmonary anthrax, pneumonic plague? What are the diagnostic criteria? How does one treat these diseases? They are among the choices of the bioterrorist.

Bioterrorism is a real, though underappreciated, possibility or perhaps probability. Bombings are overt attacks; that is, the effects are immediately obvious to anyone. During the bombing of the Murrah Federal Building in Oklahoma City, it was apparent to all what the explosion was, when it occurred, and what damage it did. Bioterrorism, on the other hand, is much more subtle. It is more difficult to determine when it occurred, where it occurred, or even whether it was a terrorist act at all. It may be days or weeks before the fact of an attack is apparent. It may be longer before the location of the attack is determined and the potential victims are identified. In the meantime, the victims may expose and infect additional people, many of whom may well be medical personnel.

The delivery of aerosolized smallpox virus in Reunion Arena during a sporting event could expose 15,000 people, who would then infect many others over a widely dispersed geographic area. Since the USA discontinued vaccinations many years ago, there is little or no residual immunity in the population. The victims would present to doctors' offices, emergency rooms, and other health care facilities. Doctors, nurses, paramedics, and other health care workers would be exposed and infected, potentially wiping out the health care infrastructure. This would leave the “second wave” of victims lacking care.

Since most physicians have little or no experience with some of the likely agents, diagnosis probably would be delayed. While procedures for isolating patients with infectious diseases are written, they are not always followed carefully. On April 6, 1983, a patient with known advanced pulmonary tuberculosis developed severe distress and was taken to the emergency department at Parkland Hospital. Fifteen people converted their tuberculin skin tests, and 5 developed active tuberculosis as a result of exposure to this patient (1). This underscores the need for emergency departments and doctors' offices to become aware of the risk of transmission of infectious diseases and put in place procedures to avoid infection of personnel and patients.

Current medical texts often contain a statement to the effect, “The clinical presentation of smallpox is now primarily of historic note,” having been eradicated worldwide in 1977 (2). But has it been eradicated? The virus is stored in the US Communicable Disease Center and in Russia. During the Cold War, our enemies were much better defined than today. The breakup of the former Soviet Union and the desperate economic stresses of the population have permitted well-funded terrorist groups to obtain biological materials and the services of scientists. Informed sources believe that former Soviet scientists are working in Iraq and that they may have taken cultures with them (Paul Laschinov, personal communication). After the Gulf War, Iraq was discovered to have a large biological weapons program (3). Usama Bin Ladin, who is foremost among terrorists, has shown a strong interest in chemical and biological weapons and has trained his operatives in their use (4). Therefore, it is widely believed that the concern about bioterrorism is not whether but when it will occur in the USA.

How can we prepare for a bioterrorist attack in Dallas? Needs include further education of physicians and public health workers on the reality of the threat; increased awareness of the signs and symptoms of some of the more likely bioterrorist agents; a system to allow communication between public health authorities, hospital emergency rooms, and practicing physicians in case of a bioterrorist attack; the cooperation of numerous governmental entities that have jurisdiction in Dallas County; and judicious reports from the news media. In addition, personal protective equipment, patient decontamination facilities, adequate stocks of antibiotics and immunizations, and adequate numbers of intensive care unit beds and ventilators will be needed. These needs are described more fully elsewhere in this issue of Proceedings.

Federal, state, and local governments have been working on plans to combat bioterrorism using the military and police and fire departments. Unfortunately, the practicing physician, who will probably be the first to see these patients, has for the most part been left out of the loop until recently. The Dallas County Medical Society has formed a Board of Health that is addressing some of these issues. Made up of experts in microbiology, epidemiology, emergency medicine, and public health, the group has been meeting regularly for >2 years to explore ways to incorporate physicians into the planning process for a biological weapons attack. The resources of the Dallas County Medical Society would be available immediately to the county health officer to alert the medical community in the event of an attack and to notify doctors of the appropriate diagnosis and treatment of patients. Teams of epidemiologists would interview victims to attempt to determine when and where the incident occurred and to trace potentially exposed contacts.

A system is in place for the reporting and identification of agents likely to be used in a bioterrorism attack. For instance, a single case of smallpox, inhalation anthrax, or pneumonic plague exceeds the normal background rate in Dallas County and would be viewed as a biological attack until proven otherwise. A sudden animal die-off or increase of background rates of brucellosis or anthrax in the animal population would trigger an investigation. Other factors being monitored include an increase of ambulance runs or emergency medical services requests; an increase of emergency calls or hospital admissions for individuals with flulike symptoms; a marked utilization of intensive care unit beds, especially for respiratory illnesses; an unexplained increase in school absences; a sudden increase in hospital admissions or clusters of disease; a sudden increase in the number of deaths in Dallas County; or a claim or substantiation of a biological attack (5).

Members of the Dallas County Medical Society Board of Health are in the process of contacting governmental officials to improve awareness and encourage preparation and cooperation.

We all hope that the ugly specter of biological weapons use--every bit as grim and foreboding as that of a nuclear winter (6)--does not come to our area. But if it comes, and it may, the medical community must have made preparations for it to the best of our ability.

--DAVID VANDERPOOL, MD
Department of Surgery
Baylor University Medical Center

1. Haley CE, McDonald RC, Rossi L, Jones WD Jr, Haley RW, Luby JP. Tuberculosis epidemic among hospital personnel. Infect Control Hosp Epidemiol 1989;10:204-210.
2. Wang F. Smallpox, vaccinia and other pox viruses. In Braunwald E, Hauser SL, Fauci AS, Longo DL, Kasper DL Jameson JL, eds. Harrison's Principles of Internal Medicine, 15th ed. New York: McGraw Hill, 2001:1115-1116.
3. Zilinskas RA. Iraq's biological weapons. The past as future? JAMA 1997;278:418-424.
4. Tenet GJ. Statement before the Senate Select Committee on Intelligence on the Worldwide Threat in 2000: Global Realities of Our National Security, February 2, 2000.
5. Dallas County Health and Human Services. Biological Terrorism Response Covert Release Recognition and Evaluation, Annex A. Dallas: Dallas County Health and Human Services.
6. Ekeus R. Iraq's biological weapons programme: UNSCOM's experience. Memorandum report to the United Nations Security Council. New York, November 20, 1996. .