There is a difference between prehospital providers' ability and willingness to respond to terrorist, public health emergencies, and disaster incidents.

A nationally representative sample of the 203,465 basic and paramedic emergency medical service providers in the United States was surveyed to assess their ability and willingness to respond to terrorist incidents.

Emergency medical technicians were appreciably (10–20%) less willing than able to respond to such potential terrorist-related incidents as smallpox outbreaks, chemical attacks, or radioactive dirty bombs (p <0.0001). Emergency medical technicians who received terrorism-related continuing medical education within the previous two years were nearly twice as likely (OR = 1.9, 95% CI 1.8, 2.0) to be willing to respond to a potential terrorist incident as those who indicated that they had not received such training.

Timely and appropriate training, attention to interpersonal concerns, and instilling a sense of duty may increase first medical provider response rates.

Terrorist attacks are exceptional events that place paramedics in high-risk situations. When terrorist events occur, paramedics play an integral role in the response to, and management of, these events. Given that responding to terrorist events places paramedics at a high risk for a variety of health problems and injuries, it is imperative to adequately prepare for such events through the use of appropriate teaching and educational programs. These programs should be based on the direct experiences of paramedics responding to previous terrorist events.

This research utilized a series of focus groups in New York and London to investigate how paramedics experienced working during 11 September 2001 and the London bombings. Specifically, this research focused on what concerned paramedics about responding to terrorist events, whether they would be willing to respond again, and what can be learned from these experiences in regard to disaster response training and education.

Paramedics reported a number of primary risks that concerned them during their responses to 9/11 and the London bombings. These included injury, death, potential contamination, and exposure to unknown hazards and agents. Personal protective equipment (PPE), communication networks, and reliabilty of information all were areas of concern that must be addressed by disaster planners. Paramedics reported that the most negative aspect of responding to these terrorist events was the inability to communicate with loved ones and the lack of timely and accurate information regarding updates on the situation. Personal protective equipment was not always available, and at times the wearing the PPE interfered with providing optimal patient care.

Key lessons can be taken away from paramedics experiences during 9/11 and the London bombings. These include the need for dedicated communication channels, accurate and timely information, suitable training and education (including an emphasis on infectious agents), and the provision of suitable PPE conducive to optimal working conditions.

Sri Lanka has experienced a 24-year civil war with monthly terrorist incidents. Disaster drills, as a method of teinforcing collaboration and improved communication, can enhance military and civil response coordination and ultimately benefit the community and the injured victim.

Two large-scale disaster drills occurred in Sri Lanka in 2008 with participation of military disaster response teams, civil hospitals, international non-governmental organizations (INGOs), the World Health Organization, American universities and hospitals, the local governments, Ministry of Health, non-governmental organizations, the Red Cross, and others. Training occurred in incident command, communication, clinical response, crowd control, evaluation, and the planning process. Civil and private prehospital care responders worked closely with the military during the drill. More than 400 participants gave active feedback and an educational video of the recorded drills was distributed for future training exercises.

Military and civil responders identified challenges and strengths and discussed improvements for future operations. In the days following the drill, participants responded to actual mass casualty incidents with improved skills, coordination and communication. Subsequent drills and task-force meetings were conducted. The INGOs supported follow-up activities and provided training materials. International partnerships were forged with military, civilian representatives, and disaster medicine specialists. Military and civil response teams had never performed a drill together before and felt it was invaluable for their coordination.

The promotion of drills involving military, civil society, and communities should be encouraged to improve response, especially in countries with ongoing civil conflict and high terrorist activity. Drills can help military and civil partners reach a broader understanding of the others' role and methodology of response, which may improve the outcome and timeliness of a disaster response.

The creation of a medical incident response plan for the treatment of injured victims contaminated during a chemical incident challenges more man one of me rescue services involved in civil emergency response. Our main objective the was to create an incident management plan compatible with existing rescue service logistics and resources.

Under the supervision of the Schutzkommission des Inneren and with delegates from emergency medical services, fire, technical rescue services, and the German Army, a consensus conference to investigate the general conditions necessary and the existing structure available for managing victims of chemical incidents, was created. Typical injury patterns and their treatment in respect to decontamination procedures were considered, the necessary structure for casualty treatment and decontamination areas were derived, and commercially available products were tested for their usefulness in this situation. Standard operating procedures and algorithms were developed to aid realization of the concept. The suitability of the personal protective equipment and the question, if under these conditions the procedures of advanced life support can be performed, was evaluated in a standardized simulator model. The necessary training for rescue personnel involved was defined. To validate the concept, an exercise was performed.

All persons present at a chemical incident are to be classified as being contaminated. Injured persons must be separated into triage categories, and life threatening conditions treated before being decontaminated. Decontamination at the incident scene is necessary to prevent the transportation of the contaminant away from the incident scene. The principles of the decontamination of injured persons are based on the following pillars: triage, early removal of clothing, management of personal belongings and valuables, basic life support, spot decontamination, management and sealing of open wounds, application of antidotes, and primary decontamination of ambulant and non-ambulant victims.

The cooperation and the definition of roles between fire services (decontamination) and emergency medical services (triage and treatment) are necessary.

The concept uses existing decontamination vehicles used for the decontamination of fire fighters, by expanding its inventory with medical equipment, and extra technical apparatus. Using a modular approach, the system can be easily augmented by further units to treat multiple numbers of victims. However, demands on all rescue services involved are high, and must be complemented with an equally high standard of training, especially where rescue services have to learn skills not akin to their standard duties. An implementation of the system covering all geographical areas with specialized units is not possible, therefore a risk analysis to optimally position limited resources has to be conducted. Legislative bodies must strive to allow for an uncomplicated integration and disposition of disaster management resources.

Accidental or voluntary chemical incidents create many health and environmental problems. According to the physico-chemical proprieties of the released agent, risks are present for all involved persons (victims, rescuers), either by primary contamination (contact with skin or mucosal surfaces, respiratory tract inhalation), or by secondary contamination from close contact with exposed victims. Recent descriptions of mass-chemical accidents with numerous spontaneous evacuations from the contaminated zone to nearby hospitals represent an important risk for secondary contamination to these hospitals.

The use of an easy-to-set-up decontamination gate to protect or preserve hospitals from contamination of their site and personnel following a massive influx of contaminated patients was evaluated. A multi-disciplinary team equipped six regional hospitals with mass-decontamination gates without mobilizing excessive human or material resources.

Basic formation of hospital personnel took two hours; attaching the gate to a local fire hydrant took <10 minutes.

This decontamination gate has several advantages and limitatins that will be discussed. However, it does have merit as an autonomous protection for non-specialized and equipped hospitals to prevent secondary contamination.

Disasters and emergencies involving radiation can produce numerous social and behavioral impacts, including shadow evacuations, seeking of medical attention by large numbers of people fearful of potential contamination, and stigmatizing of individuals, products and communities perceived to be associated with the incident. Indeed, these, and related impacts, can constitute some of the most important and challenging public health effects of a radiological-nuclear incident. At the present time, it is unclear whether or how such issues are being addressed in preparedness training exercises.

With support from the Radiation Studies Branch, Centers for Disease Control and Prevention (CDC), a study (2006–2008) was performed by researchers at the University of Alabama at Birmingham. The aim was to determine how social and behavioral issues are addressed in radiological-nuclear exercises. Radiological-nuclear exercise reports, guidance materials, and related items were gathered, and a systematic review and analysis of the documents was conducted.

Initial findings from the study suggest that only about half of radiological-nuclear exercises deal with key social and behavioral issues. Where such issues are included, they tend to receive relatively litde attention, components are typically small in scope, and the most difficult challenges often are “assumed away.”

Even though social-behavioral issues are central in radiological-nuclear incidents, opportunities to practice coping with them in training exercises are quite limited. If preparedness training is to be realistic and useful, this problem urgently needs to be addressed. The present study provides a series of recommendations toward this end.

The medical system has an important role in response to a radiological emergency. Although the Radiation Emergency Medical Preparedness and Assistance Network (REMPAN) exists, every country must provide elements of preparedness of a national medical system for managing radiological emergencies.

A research group consisting of experts reviewed the literature and related plans; International Atomic Energy Agency (IAEA) standards also were considered. Based on a three-level approach, preparedness elements of the national medical system were determined.

An emergency medical services (EMS) team for each district is to be trained. The competence of the team members, requisite equipment, procedures for rapidly preparing an ambulance, triage, and decontamination procedures were compiled. For each province, a prepared general hospital and its teams should develop: (1) radiological assessment capability; (2) triage; and (3) decontamination preparedness intervention. A radiation emergency receiving area, equipment list, personal protective equipment, and cooperation with specialized centers were considered. Each country must have a specialized hospital for medical management, training, and connection with REMPAN. All specialized departments, unique instruments, specific drugs, and'necessary procedures were defined. Also, tlie development of a mobile medical support team that could be accessed from the region.

Although radiological emergencies are rare, a national medical system must provide a comprehensive emergency management plan and be prepared for incidents.

The response to hazardous materials or chemical, biological, radiological, nuclear (CBRN) incidents typically consists of: (1) cordons regulating access into and egress from designated zones; and (2) use of appropriate personal protective equipment. In most systems emergency medical services (EMS) will stay outside of the “hot zone”. The patient will be rescued by the fire service and, after some gross decontamination, handed over. As mass gatherings are regarded as high-risk events, this system was used in Vienna during the Euro08 and augmented by: (1) casualty decontamination units (seven parallel lines for stretcher decontamination, located before triage); (2) a rapid intervention group for medical care in the hot zone (25 medical personnel), responsible for triage, life support (airway, breathing, bleeding), and antidote therapy; and (3) a joint CBRN incident command for close cooperation with detection units.

After a review of the available open-source literature, a risk analysis was performed and the tactical concept described above was developed with cooperation of all involved services. Special training was performed for all members of the aforementioned units.

As the concept was not tested by an actual emergency, the following observations can be made: (1) readiness of the units could be successfully maintained during the EURO08; (2) me chosen equipment was experienced as appropriate; (3) several minor cases corroborated the risk analysis; and (4) manpower and training requirements were considerable.

While it is possible to perform medical care within the hot zone, concepts are rarely tested in reality and the necessary efforts raise the question of proportionality.

Although 15 years have passed since the Tokyo subway attack, it was the preparations for the Kyushu-Okinawa G8 summit (2000) five years thereafter that catalyzed the development of countermeasures and policy against chemical, biological, radioactive, nuclear, or explosive (CBRNE) threats in Japan.

Report: No substantial progress was made for five years after the subway attack. Preparedness for the Kyushu-Okinawa G8 Summit included promulgation of the Civil Protection Law (2004), which codified the responses to CBRNE terrorist attacks, and consequendy, the effectiveness with which the countermeasures against CBRNE terrorism acts could be deployed at a national level. Countermeasures included the establishment of a CBRNE task force, syndromie surveillance programs, and the stockpiling of antidotes, antitoxins, and antibiotics. Decontamination facilities were introduced throughout Japan.

Preparedness for the summit facilitated recognition of the need for medical countermeasures against CBRNE threats to protect healthcare providers in Japan. In the 15 years since the Tokyo Subway Attack, the measures implemented in the last five years have been most effective. However, future challenges include the promotion of civilian awareness, inter-agency collaboration, and increasing the mutual-aid capacity of local communities.

The response to incidents with chemical and radioactive substances has been shaped primarily by firefighters' experiences with hazardous material (HAZMAT) accidents. Globally, HAZMAT tactics consist of the main elements of: (1) appropriate use of personal protective equipment; and (2) cordons regulating access into and egress from designated zones. Detection and casualty decontamination are far less uniformly organized.

Review and analysis of open-source (medical-and first responder-oriented) English and German Ianguage literature; informal questionnaire survey of first responders in several European countries.

The initial on-scene measures during a HAZMAT response—cordoning off the scene and rescue out of the contaminated area—are done uniformly by fire service responders. In most cases, emergency decontamination of casualties at the scene (disrobing and flushing), is performed by firefighters, however, reliability appears variable. The probability of a coordinated patient handover from fire personnel to emergency medical services (EMS) staff is rated “low” by most sources.

In many countries, specialized casualty decontamination units have been commissioned and are operated by a variety of services: fire, EMS, military and civil protection.

Hospital decontamination facilities are in most countries still the exception and depend mosdy on local commitment. Substantial detection usually invalues only simple measurements performed by the first responders; specialized support is planned to be given mainly by military, civil protection and specialized laboratories.

Initial on-scene response to chemical/radiological incidents is fundamentally similar in most countries. However, distinctive differences beyond the first steps restrict the transferability of organizational solutions.

The objective of this study was to assess the effect of 20 minutes of heavy treadmill exertion in military-style, Level-C chemical and biological personal protective equipment (PPE), including a filtering face piece respirator, on physiological variables including venous pH, venous PCO2, SpO2 and tympanic temperature.

Baseline physiological variables were measured in 19 healthy subjects who undertook heavy physical exertion on a treadmill at a constant room temperature of 20°C: (1) once while wearing a short-sleeved t-shirt, shorts, and running shoes; and (2) once while wearing chemical and biological PPE. Repeat measurements of physiological variables were made after 10 and 20 minutes of exertion in both groups.

Twenty minutes of physical exertion was undertaken by healthy subjects wearing chemical and biological PPE resulted in moderate hypoxemia, significantly decreased pH (p = 0.003), elevated PCO2 (p = 0.018) and elevated tympanic membrane temperature (p < 0.001), compared to baseline values. Despite these significant differences, none of the mean venous blood gas values deviated from the normal range during physical exertion.

The degree and duration of physical exertion undertaken in chemical and biological PPE induced some significant changes in physiological variables compared to control but, with the exception of SpO2, did not result in changes considered to represent abnormal physiology. However, it is likely that core body temperature was underestimated by tympanic measurement. Blood gas data indicating that CO2 was retained during exertion in this type of PPE were unanticipated and require further investigation.

Emergency medical services (EMS) providers are ill-prepared in the areas of training and equipment for weapons of mass destruction (WMD) events and other public health emergencies.

A nationally representative sample of the basic and paramedic emergency medical service providers in the United States was surveyed to assess whether they had received training in WMD and/or public health emergencies, as part of their initial provider training and as continuing medical education (CME) within the past 24 months. Providers also were surveyed as to whether their primary EMS agency had the necessary specialty equipment to respond to these specific events.

More than half of EMS providers had some training in WMD response. Hands-on training was associated with EMS provider comfort in responding to chemical, biological and radiological events and public health emergencies (OR = 3.2; 95% CI = 3.1–3.3). Only a small portion (18.1%) of providers surveyed indicated that their agencies had the necessary equipment to respond to a WMD event. The comfort level and having equipment to respond these incidents was not as highly associated as the comfort level and having had training to respond to these incidents.

Lack of training and education as well as the lack of necessary equipment to respond to WMD events is associated with decreased comfort among emergency medical services providers in responding to chemical, biological, and radiological incidents. Better training and access to appropriate equipment may increase provider comfort in responding to these types of incidents.