Joseph F. Waeckerle, MD FACEP

Editor Emeritus, Annals of Emergency Medicine Clinical Professor, University of Missouri

Domestic Preparedness

for Weapons of Mass Destruction

September 11, 2001

Asymmetric Warfare

Amerithrax 9/18/01

America Challenged & Changed

Goals “Protect and Preserve”

Disaster Medicine

Safety & Well-BeingPropertyEconomy & InfrastructureEnvironment

Realistic simulation scenarios have demonstrated that some local communities are ill-informed, poorly financed, not well

trained or drilled, and not integrated into the

federal response system that will be inevitably introduced into any incident.

Disaster Medicine

Disaster Medicine

Define the Community & StakeholdersCommunicate & Collaborate

Develop Clear and Cogent PlanIntegrate & Coordinate

Cultivate & Sustain

Planning Process

Disaster Medicine

Objective Assessment

Realistic Planning Requires:

Risk AssessmentThreat/Assets/Vulnerabilities

Analysis

Disaster MedicinePlanning

Asymmetric Warfare TargetsDisaster Medicine

HumansAnimals

PlantsWater

EnvironmentIncreasing Spectrum

ConventionalBiologicChemical

Radiation/Nuclear

Disaster MedicineAsymmetric Warfare Threat Agents

Increasing Spectrum

Conventional Agents

The weapons of choice

Anthrax Incident demonstrated multisystem failures and an undermining of public

confidence11 Cutaneous

22 Cases11 Inhalational

5 Deaths

FL (2) , DC (5), NJ (7), NYC (7), CT (1)

Biologic Agents

Chemical Agents

+ =

Radiation Dispersal Device

Nuclear Weapon

or =

The Future Of Warfare…Unmanned Aerial Vehicles

Think “out of the box”!

Threat Analysis

Behavioral Behavioral ResolveResolve

Technical ExpertiseTechnical Expertise

Operational Experience

Behavioral Resolve

By one of our own against our own !

“Zealots, extremists, and malicious opportunists will not be constrained

by moral and ethical considerations”

Risk Analysis

Disaster MedicineRisk Assessment

Prioritize Primary and SecondarySequelae

of Agent/Target

Risk AssessmentAsset Analysis

Disaster Medicine

Community “Level of Preparedness…”Current assets...

Surge assets... Outside assets...

Risk AssessmentVulnerability analysis

Disaster Medicine

Severity of Risk & Severity of Outcomevs.

Level of Preparedness

Terrorism from within…

America is vulnerable

America is vulnerable

Terrorism from without…

What we need...What we have

America is vulnerable…

Plan…“Bridge the Chasm”

Disaster Medicine

Objective AssessmentComprehensive Plan

Realistic Planning Requires:

Disaster Medicine

Fail to Plan...Plan to Fail

It is too late to plan a response once a disaster has occurred

Comprehensive Plan

Disaster Medicine

Fail to Plan...Plan to Fail

so“Create or Adopt & Adapt”

Comprehensive Plan

Local/State /Federal Partnership

Disaster Medicine

All disasters are local…

Disaster Medicine

Community Response First

State Response Follows…Federal Response Follows…

Planning

Dependent on others….

Local Community

Help is “on the way.”

Dependent on self for 24-48 hours!

Local Community

“Urban Centrism”

United States policy is focused on urban areas

Disaster MedicinePlanning

From a strategic standpoint, rural areas are especially vulnerable and may represent

substantial threat to security.

Disaster MedicinePlanning

Its not about killing cows or plants!!

Economic assault •16% of US Workforce•11% of GDP•8% of US Exports

Agricultural Targets

All infrastructure established to respond to terrorism should have

“dual-use” goals

Disaster MedicinePlanning

Al Hakam

“324”

Two 1,450 liter fermentersIraq’s most sophisticated and largest biological weapons R&D

facilityAllegedly produced single-cell protein for animal feed

Can produce beer too!

“Dual Use”

Disaster Medicine

Objective AssessmentComprehensive PlanCalculated Actions

Realistic Planning Requires:

Unique characteristics of WMD threats impose the need for a

unique defense doctrine for each threat category.

Disaster MedicineCalculated Actions

All Hazards Approach

“One for All...

... All for one”

Disaster Medicine

“The Right Response for the Right Agent”

Calculated Actions

"biological weapons can be produced and delivered by a few…

present a small signature for which the U.S. has ill-developed intelligence gathering capability…

conventional concepts of deterrence are not necessarily effective…

the nation has a limited response capability to contain the consequences…"

Defense Science Board July 2002

Biodefense is the "single most significant

modern challenge to U.S. sovereignty"

Scope of Bioagent Incident

42

PlanningDevelopmentAcquisition

Delivery

Release

Dispersion

Exposure

Incubation

Symptoms

Outcomes

Motivation

Forensic Investigation Attribution and

Retribution

Faster Detection, Care & Containment

Pre-emptive Interdiction Strategic

Points of Interventions for

More Efficient & Effective Incident Management

End of IncidentDefense Science Board July 2002

Countering Bioterrorism

IntelligenceAgentAgentDelivery SystemDelivery SystemOrganizationOrganizationTimeTime

Physical CountermeasuresDetectionPhysical ProtectionDecontamination

Medical Countermeasure sVaccines / ProphylaxisDiagnosticsTherapeutics

Biological Biological DefenseDefense

Education & TrainingMilitary and Civilian Health Care ProvidersElectronic CommunicationDistance Learning

Darling

Conventional Response“Escalation of our everyday emergency response system”

The Right Response

“Incident planning is extremely complex requiring swift interdiction by a plethora of local, state, and federal agencies in collaboration with an equally diverse array of non-governmental

organizations”

The need for mutual aid and specialized response teams must be

anticipated and addressed!

Unconventional Response

The Right Response

Special Response

Private Industry Mutual Aid

Private Citizens

NEST Team

Police/SWAT

Hazmat

Disaster Medicine

Objective AssessmentComprehensive PlanCalculated ActionsResourceful Personnel

Realistic Planning Requires:

Disaster Medicine

Disasters are defined not by the absolute number of casualties but

by the level of personnel and resources needed to adequately meet the demands

Planning

First Responder community is the same and different

Local civilian medical and public health systems are now first responders and all responders are

critical human infrastructure

Disaster MedicinePersonnel

The Trinity of Local Response

Health Care Health Care FacilitiesFacilities

Public Public HealthHealth

Responders/Health Care Responders/Health Care ProfessionalsProfessionals

Command & Command & ControlControl

Health Care Professionals

The “new & critical” first responders

Realistic simulation scenarios also demonstrated that local responders suffer

from a lack of knowledge of the disaster plan and experience

in delivering the plan…

Disaster MedicinePersonnel

Health Care ProfessionalsMinimal InvolvementUnfocused Education and Training Inadequate FundingOverextended in Providing Emergency and “Safety Net”

Care

Disaster Medicine

Disaster MedicinePersonnel

Physician/nurse involvement should include the pre- disaster, the response and the recovery phases

but their involvement on scene is controversial !

Disaster Medicine

Perform best if they areAssigned duties similar to their professional dutiesUnderstand command and their roleTrained and practiced in “hostile” environmentAnticipate stresses

Personnel

PersonnelEducate = KnowledgeTrain = PerformanceTest ≈ CompetencySustain = Perishable Skills

Disaster Medicine

Disaster Medicine

The delivery of medical care during a disaster response especially in the field is radically

different & extremely demanding

Personnel

Disaster MedicinePersonnel

Search and Rescue CascadeRapid accessAccurate triageAppropriate treatment

and evacuation

Disaster MedicineSearch & Rescue

Secure first and

rescue second

Don’t become a victim !

Disaster MedicinePersonnel

TriageProcess of prioritizing victims for

treatment and transportationBased on salvageability and immediacyBalance resource supply and demandDynamic

Disaster MedicinePersonnel

TriagePerformed by an experienced, objective and

informed HCP’s utilizing simple criteria without the

need for equipment

Disaster MedicinePersonnel

TriageConventional

“Prioritize without compromise”

Life Saving Care, No Matter Where !

Disaster MedicinePersonnelTriage

Disaster (Field)“Prioritize with compromise”

“Austere Care”

Disaster MedicinePersonnel

TriageProperly done triage is the

sine qua non of optimal care for all !

Disaster MedicinePersonnel

The mental and physical demands are tremendous

Superman Myth

No one involved is unscathed !

Disaster MedicinePersonnel

CISM should be addressedbefore, during and after an incident

Former Trauma Surgeons

Disaster Medicine

Management System is fundamental to

an effective and efficient response

PersonnelRetired Trauma Surgeon

No Authority StructureDecays Mitigation Efforts

Undermines Partnership among Federal, State and Local Communities

Disaster Medicine

Disaster Medicine

One organization with “universal”representation creates strong synergy

Results in functional clarity in responsibility & action

Unified Command System

Disaster MedicineIncident Command System

Most knowledgeable, skilled and experienced leaders take charge….

Chief Joseph His BravesLeading into BattleChiefCrazy Horse

Disaster Medicine

Objective AssessmentComprehensive PlanCalculated ActionsResourceful PersonnelSufficient Resources

Realistic Planning Requires:

Disaster MedicineResources

Resource management is critical due to no resources, too little resources or

too much resources

Disaster MedicineCommunications

Most common problem and

very difficult to solve

Communication and exchange of data are essential before, during and after an

incident !

Disaster MedicineCommunications

Redundant “Fused”

Communications SystemsSimple

Common

InteroperabilityReliable

Advanced

Disaster MedicineCommunications

Activating the disaster plan is difficult due to the enormous political, economic and social

consequences yet swift interdiction saves lives !

Disaster MedicineCommunications

A public communications strategy & information officer are essential to liaison with the

media/public

Clear Credible

Consistent

Disaster MedicineCommunications

Facilitates information sharing with law enforcement, intelligence and defense

SWAT Scientist

Spy

Disaster MedicineSupplies and Equipment

Get the right amountof the right resources to the right place in the right time !

Security

Maintain safety

Disaster Medicine

SecurityControl scene

Disaster Medicine

“Convergence Behavior”Outside

Inside

Disaster MedicineWMD Incident = Crime Against Humanity

Robust Forensic Investigation

Attribution&

Retribution

Disaster MedicineTransportation

Available/AppropriateOn-going Communications

Disaster MedicineFatality Collection Area

Near but isolated Facilitate identification

and investigations Minimize exposure

Disaster Medicine

Record Keeping“Paperwork is a priority”

Accurate and timely information is important during all stages of the response to identify victims and their

location, document on-going care, aid the investigation and evaluate the response

Disaster MedicineHealth Care Facilities

Minimal Integration

Maximal Challenges

“The lack of integration of health care facilities in the overall community response is a serious

flaw in US national strategy.”

Disaster MedicineHealth Care Facilities

Disaster MedicineHealth Care Facilities

Unfunded Mandates & Fiscal CrisisConcern of Contamination/Closure? Reimbursement Policy? Litigation Protection

Time & Money

Contamination & Closure

Health Care Facilities

The EDThe “Achilles Heel”

of

Domestic Preparedness

Disaster Medicine

America’s Safety Net for Health Care ?

The ED

The EDOver-crowdedUnderstaffedInadequate design and resourcesNo surge capacity

Disaster Medicine

America’s Safety Net for Disasters ???

The ED

The ED Staff

“ Educate, Train, Test, Sustain”

lack of Money lack of Time lack of Commitment

Disaster Medicine

Trained and practiced ?NOT

Disaster Medicine

The ED“Beware the Walking Wounded

thenBeware the Worried Well”

Keep patients in the System

Medical Management Capabilities

Deficiencies

Hospital Beds&

Hospital Personnel

Disaster Medicine

Medical Management Capabilities Deficiencies

Vaccines for PreventionAntibiotics/Antidotes for TreatmentCritical Supplies/Equipment for

Supportive Therapy

Disaster Medicine

Vaccination Program

Federal Partnership with Pharmaceutical Industry

Antibiotics/Antidotes

Supplies and Equipment

2/3 of a Push Package

Public Health System Building and better but still

fragile!

Disaster Medicine

Communication/Coordination in community need

more investment

Disaster MedicinePublic Health System

Public Health System Disaster Medicine

Surveillance, Investigation& Treatment capabilities

lack Personnel and Money

Detection & Identification capabilities are improving

but not optimum

Disaster MedicinePublic Health System

Gram-positive bacilli in long chains

Community Public Health Still Require:

Trained PersonnelModern TechnologyLaboratory CapacitySufficient Funding

Disaster Medicine

Disaster MedicineKnowledge ≠

Performance

Disaster DrillsCarefully planned, clear objectivesVarious types, different experiencesFosters coordination/communicationSolutions developed by knowledge/experience

“EXPERTS MADE”

Conclusions

Land of the free because of the brave !

The “Calculus of Risk”

has changed dramatically due to the threat of

WMD agents suitable for asymmetric warfare

Disaster Medicine

Although the probability of an incident is

difficult to assess, the medical, social, economic and political consequences

of

any incident will be disproportionately high.

Disaster Medicine

Assumptions

Commitment & Culture

Coordination &Communication

Capability & CapacityCare & Containment

Improve & Sustain

Command & Control

Disaster Medicine“Massive Vulnerability”

butSignificant leverage points to produce dramatic gains in defense capabilities

Politics can not trump Science

Keys for SuccessPrepared responseQuick responseCoordinated responseSustained response

Disaster Medicine

Disaster Medicine

Triage Goal=Disaster Goal“Get the right patient to the right hospital

by the right means in the right time”

“The Golden Rule”

Disaster MedicineThe Dynamic Process of triage

applies to all aspects

of a

disaster response

Benefits of Comprehensive Response Strategy

Deter BehaviorMitigate ConsequencesProsecute Criminals

Difficult, yes. Too hard, no!

Disaster Medicine

"The Boss Mayor”

“Ultimately, you do the best you can

and hope that it is the best that can be done.”