MASSACHUSETTS NURSE NEWSLETTER :: June/July 2004

Hospitals: will they be ready when the terrorists are?

By Larry Ferazani

Emergency preparedness in the U.S.

In 1986, Congress passed the Emergency Planning and Community Right to Know Act, also known as Title III of the Superfund Amendment and Reauthorization Act (SARA Title III). This act addresses hazardous materials emergency planning, emergency notification and reporting of annual routine releases of chemicals to the environment. Under the act, the governor of each state must appoint an Emergency Response Commission. They in turn must appoint local emergency planning committees.

The local emergency planning committees (LEPCs) develop written response plans addressing hazardous materials tailored to the needs of their communities. The State Emergency Response Commission has the responsibility of reviewing these plans to ensure hazardous materials training is conducted. In May 2001, the United States Environmental Protection Agency published a fact sheet, LEPCs and Deliberate Releases (EPA 550-F-01-005). It instructs local emergency planning committees to incorporate counter-terrorism measures into their plans.

Unfortunately, when this act passed in 1986, it was an un-funded mandate and is still un-funded. This fact alone has caused the implementation of the policies by communities throughout the country to be fragmented. The new Department of Homeland Security doesn’t address SARA Title III in its plans or funding?making it even more difficult for the states and the community LEPCs to comply with the Superfund Amendment.

The Department of Homeland Security is focused on prevention and law enforcement, as it should be. Before the Department of Homeland Security became responsible for the preparedness of this country to respond to terrorism, the Federal Emergency Management Agency (FEMA) was the lead response agency in disasters. In 1992, FEMA faced criticism for its slow response to the Hurricane Andrew disaster in South Dade County, Fla. At that time those criticisms were unjustified as FEMA was grossly under-funded by Congress and the public had a misconception of what FEMA’s role and capabilities were.

FEMA, the federal response, the state response agencies and Congress learned what unprepared meant. In response to the lessons learned, FEMA became a formidable disaster response agency under the tutelage of James Lee Witt, who was appointed director in 1993. FEMA’s management of disasters and its coordination with State Emergency Management Agencies was unparalleled in the country’s history of disaster response.

But the establishment of the Department of Homeland Security seems to have placed FEMA in a back seat role and is slowly disassembling what was one of America’s great success stories. Some current effects of this is that FEMA grants to the states for planning and training have been significantly reduced and replaced with a more difficult and confusing system. The local emergency planning chairman sits at the bottom of this confusing matrix and tries to figure out how he can fund and implement the federal law effectively.

Hospitals in the line of fire

Recently U.S. Rep. Barney Frank of Massachusetts was asked if hospitals were ready for a terrorist attack. He stated, "Hospitals are not ready for Saturday night, let alone a terrorist attack."

Most hospitals are finding it increasingly difficult to keep their doors open. With the closing of many hospitals, the burden falls on the remaining medical facilities to serve a larger community. It has been widely reported that over 1,000 emergency rooms have closed in this country over the past ten years. Hospitals report long lines of patients waiting for medical attention in emergency rooms on a daily basis. ‘Divert’ is a term heard quite frequently. Hospitals become so backed up with patients that they are forced to contact their communication centers to divert ambulances, which are then directed to take their victims to other hospitals. Unfortunately this could not have happened at a more critical time in our history.

Hospitals are now faced with the need to prepare themselves to be on the receiving end of the fallout from a terrorist attack. Hospitals have become the core of the community’s plans to receive, identify and treat contaminated victims of a terrorist attack, an expectation that will be difficult to meet given that most hospitals are not provided with the right financial resources to meet this need.

OSHA, in its 3152 information booklet, gives guidance to hospitals for emergency response. OSHA specifically points to a section of the Environmental Protection Agency law, SARA Title III, as a reference that states, "In planning for emergencies, Local Emergency Planning Committees must designate a hospital that has agreed to accept and treat victims of emergency incidents. The designated local hospital is required to send a representative to participate with the LEPC as part of the community’s emergency response organization."

Personal experience

I must admit that complying with this section of SARA Title III was probably the most difficult for me. Recruiting hospitals to send representatives to an LEPC meeting before Sept. 11, 2001 was sporadic?after Sept. 11 it did become a little easier. This was not always the case in many communities. When we went throughout the state to deliver our training program to hospitals, hospital staff told us that, in many instances, their hospitals serviced a number of different communities and it was impossible to send representatives to every LEPC meeting.

So here lies the crux of emergency planning: If hospitals do not participate with their Local Emergency Planning Committees in planning for terrorism, what can the community expect to happen during a real event?

Historical events could provide clues to responses in the future

• 1979: Three Mile Island, Pa.
  The nuclear reactor suffered a partial meltdown. It wasn’t until the third day of the disaster that the governor of Pennsylvania decided to recommend evacuation and only for pregnant woman and pre-school children. Emergency managers were told to plan for a 20-mile evacuation on that Friday. An evacuation would have included six counties, 650,000 people and 13 hospitals if the order came. About 2,000 people submitted injury claims for gamma radiation exposure. There was a call for potassium iodide (a drug that is capable of preventing radioactive iodine from lodging in the thyroid). No pharmaceutical company or chemical company was marketing medical grade potassium iodide in the quantities needed at that time.
  
• 1995: Sarin attack on subway, Tokyo
  Over 1,300 EMTs were dispatched to the scene of a nerve gas attack and more than 135 suffered from secondary exposure. St Luke’s Hospital reported that 25 percent of its medical staff complained of symptoms of secondary exposure. Fire departments, police and local government agencies responded independently, but without coordination. In all, 6,000 people were exposed, 3,200 were taken to hospitals, 490 were admitted and 12 victims died.

Responses to terrorism start at the local level

Communities, already facing their own financial difficulties, are confronted by the need to train their public safety employees, including community officials, to respond to terrorism. Local Emergency Planning Committees are charged with the responsibilities of developing a plan for the community’s response. Unfortunately, because of financial shortfalls, their plans are designed under old models of response and, in many cases, with a lack of standards, including the usage of personal protection equipment. Old planning models for example call for the triage of victims of a terrorist event at the scene, immediately followed by transportation to local hospitals.

Hospital personnel earlier in their history were not faced with contaminated casualties from possible biological or chemical exposure. In those days responders would rise to the occasion and perform their clinical duties both heroically and admirably. With the growing threat of biological, radiological and chemical contamination, transporting victims directly to the hospital after triage is unrealistic and is a prescription for failure. Transporting more than five victims from an accident to a local hospital is challenging enough. Add contamination from a terrorism attack and the situation changes dramatically. Hospital personnel would be faced with identifying the agent used and assessing the clinical implications of the contamination, as well as protecting themselves, their staff members and hospital patients from the spread of the agent.

Clinicians may not know, for example, if their families are safe and if they themselves could be a threat to their families if they become infected. In addition, they may need to get medical supplies, such as antidotes, within hours or even minutes. Untrained pre-hospital members could be transporting contaminated patients right to the front door of the hospital.

Creating a new model

New models must be created with the help of local emergency planning committees, FEMA and the states. In military engagements, where large numbers of casualties are sustained, there are levels of evacuation. Decontamination and medical care is staged and rendered from the battlefield to the field hospitals. Contaminated patients do not arrive contaminated to any military hospital. No civilian victim, unless they are walk-ins, should be anywhere near a hospital after a catastrophic terrorism event.

Decontamination should be accomplished at the initial site of attack and then victims sheltered and medically screened before being deployed to a medical facility. EMTs and paramedics should consider setting up first aid clearing stations rather than staging areas for the immediate transport of victims to a hospital.

One excellent strategic initiative is the Massachusetts Department of Public Health’s plan to establish vaccination and/medication dispensing sites, while still another is that pre-hospital personnel are beginning to carry chemical antidotes for self protection. Again, many hospitals are slow to participate in these plans and they continue to be vulnerable because the entire system is unprepared.

Conserve our first responders

OSHA needs to become more specific in its recommendations for hospital staff protection and training. In many instances standards are now open to interpretation. For example, OSHA says that hospitals should implement the following:

• Pre-emergency drills implementing the hospital’s emergency response plan.
• Practice sessions using the Incident Command System in coordination with other local emergency response agencies.
• Lines of authority and communication between the incident site and hospital personnel regarding hazards and potential contamination.
• Designation of a decontamination team, including emergency department physicians, nurses, aides and supporting personnel.
• Description of the hospital’s system for immediately accessing information of toxic materials.
• Designation of alternative facilities that could provide treatment in case of contamination of the hospital’s emergency department.
• Plan for managing emergency treatment of non-contaminated patients.
• Decontamination procedures and designation of decontamination areas (either indoors or outdoors).
• Hospitals cannot possibly implement these standards without comprehensive training for their physicians, nurses and ancillary employees.
• Hospitals cannot possibly implement these standards without coordination from their local emergency planning committees.
• Hospitals cannot possible implement these standards without proper protective clothing.
• Hospitals cannot possibly implement these standards without proper decontamination stations away from the hospital, either mobile or fixed.
• Hospitals cannot possibly implement these standards without funds.

Training

Most hospitals do not have full-time emergency preparedness personnel within their facilities. In many cases, I find that the director of nurses, nurse training directorates, emergency department physicians or hospital-based paramedic coordinators valiantly take on this role. I have met very few hospital administrators who take an interest in this issue. Some of the reasons are that they legitimately lack funds and others could be that there has been little or no enforcement of the SARA Title III Law or OSHA’s Worker Protection Laws.

Cottage industries have sprung up all over the country to deliver training and provide personal protective equipment to hospitals. The training and selection of the PPE in most cases is not coordinated with the local community planning committees and in many cases, lack quality control standards and guidelines. During the implementation of the color coded threat levels the federal government put confusing guidelines for evacuation and shelter in place. The issues of evacuation or shelter take on a significance not seen since after World War II or during the cold war. Sirens would sound and citizens would follow the guidelines set down by the Civil Defense Agency. Sirens have gone and the guidelines for the public are confusing.

First responders would be faced with insurmountable problems implementing either decision today. Hospitals are not impervious to a toxic or biological gas attack and need to be trained to both shelter in place and evacuation, given the high degree of difficulty to implement either option.

Massachusetts before September 11

The Massachusetts Emergency Management Agency, through its State Emergency Response Commission, saw the need for training hospitals to respond to terrorist or accidental events involving hazardous materials well before September 11 and spent months developing a program with the input and cooperation of hospitals in the greater Boston area. Many hospitals have stepped up to the plate and are well on their way to becoming well prepared, but many others have tried to prepare without hospital administrators supporting this effort. Their training will be fragmented and ineffective. The Massachusetts Nurses Association, understanding the risks of terrorism, took a lead role in presenting the state’s program to its members.

The Environmental Protection Agency is responsible for the implementation of SARA Title lll. The act has been in effect since 1986 and yet still lacks recognition by the other agencies in the federal government.

A solution

A possible solution is complicated, but should be reviewed. FEMA should be brought back to its former standing and the director should be given cabinet status. The Department of Homeland Security, Congress, governors and mayors must recognize and understand the Federal Law on Hazardous Materials response, SARA Title III law should be fully funded and distributed to EPA and FEMA then directed to State Emergency Response Committee’s to invigorate local emergency planning committees. SERCs must undertake the training and oversight of these committees. The law is specific, comprehensive and workable. Hospitals could accomplish community planning goals in a far more effective way. All terrorism responses will start at the local level and the public would not want their community hospitals closed because they have become contaminated and therefore unable to deliver medical care. The public would not want to have their community hospital personnel undergo injury or loss of life because the hospital failed to train or equip them.

Larry Ferrazani's comments in this article are appreciated by the members of the Massachusetts Nurses Association, Emergency Preparedness Task Force members and others who are concerned about the level of hospital and community preparedness. His comments provide us with background information to discuss the issue and advocate for funding and actions that will result in greater awareness, better training and appropriate preparedness to respond, should the events we hear and see about daily in other countries, happen here…again.

Ferazani delivers a course on "Hospital Response and Hospital Incident Command" that addresses responses to accidental or planned chemical, biological and radiological events and for the past 15 years, Ferazani has delivered this course to hospitals and the pre-hospital communities in Massachusetts.

Recently Ferazani has been contracted to teach this course in Vermont. Larry has just retired as the chairman of the Cambridge Local Emergency Planning Committee, which he served on for 17 years. Larry served 25 years as a medical service corps officer in the U.S. Army Reserve. He was as an advisor to a 1,000-bed general hospital during the Vietnam War and eventually commanded a 1,000-bed reserve general hospital. His last assignment was a first Army liaison officer in support of civil defense and key asset protection planning against terrorism. He retired from the reserves in 1993 as a full colonel. He also worked for the Cambridge Fire Department in Massachusetts, where he spent 10 years on the Cambridge Rescue Squad. He taught chemistry of hazardous materials at Bunker Hill Community College for 15 years. He wrote three books about his experiences working on the rescue squad, Rescue Squad, The Maltese Cross and The Last Spartans. Larry graduated from the Army Command and General Staff College and the hospital administration program at Ft. Sam Houston, Texas.

Ferazani and his colleague, Anthony Fucarolo, EMT, have periodically presented a program at the MNA since January of 2002, "Emergency Medical Response to Hazardous Materials and Acts of Terrorism"

For information on any of these programs, contact Chris Pontus in the MNA Health and Safety Program.