*Enclosure 7-4*

S A M P L E

Chemical Event

And Terrorism Readiness Plan

1\. ***Introduction***. The Chemical Event and Terrorism Readiness
(ChETR) Plan is a component of the VA Medical Center (VAMC) Emergency
Operations Plan (EOP) that addresses the unique characteristics of a
chemical release or spill. The ChETR Plan is to be used for any chemical
hazard or threat, accidental or intentional, that may be encountered by
the VA Medical Center or any community emergency event in which the VA
Medical Center may be asked to assist. The Plan is structured to use the
Incident Command System (ICS) and implement Standard Operating
Procedures (SOPs) for any specific chemical event that is likely to be
encountered. Special considerations must be given when considering a
chemical event that is internal to the facility versus an event external
to the facility outside of the danger or plume zone.

Initial recognition of a chemical event is usually not problematic. With
a few important exceptions, a spill or release of most chemical agents
cause abrupt onset of symptoms immediately recognized as dangerous
and/or life threatening by the individuals exposed. Key in the initial
response, coordination of communications and ongoing activities at the
site of the spill or release, will be technician level trained first
responders from local fire departments and other emergency medical
service personnel. Firefighters and hazardous materials (HAZMAT) teams
trained at the technician level are the only personnel that should be
dealing with the true "hot zone" at the site of the spill in which the
potential for conditions immediately dangerous to health and life (IDHL)
exist. Secondary responders, or personnel with a special need to enter
the spill site zone, may do so under the direct supervision and guidance
of trained first responders. Hospital personnel preparing to receive
patients from the zone of exposure, implement hospital decontamination
procedures and treat patients being transported from the zone of
exposure to the hospital are classified as hospital based first
receivers. Hospital first receivers by definition are operating in a
clean zone away from the site of the spill or release, and wear a
minimum of OSHA (Occupational Safety and Health Administration) Level C
personal protective equipment (PPE) to protect them from contaminants
contained on the clothing or skin of the victims who are arriving at the
facility. Pre-planning for potential events based upon local risk and
hazards vulnerability analysis (HVA) and involvement of a
multi-disciplinary hospital response team is key in a successful safe
response.

Both accidental and intentional events should be considered when
developing response plans and conducting drills to prepare for a
potential chemical event. Historically, medical centers are most
prepared for dealing with casualties from a small accidental chemical
release, such as that from an industrial site or transport vehicle in
which the agent is immediately known due to Department of Transportation
(DOT) regulations requiring standardized labeling of both transportation
vehicles and containers. Expectations in the accidental spill/release
setting are that there will probably be a small number of patients
arriving, that the agent will be known or declared by the time the
patient arrives and that most seriously contaminated patients will be
decontaminated at the site of the spill by first responder HAZMAT teams.
Household spills may only involve one or two individuals and the history
of how and why the spill or exposure occurred is usually well
documented, along with the offending agent.

The story is expected to unfold quite differently in the setting of an
intentional or terrorist chemical release event. A few situations that
may indicate the possibility of a Chemical Warfare agent release include
the following:

-   Unusual, unexplained outdoor animal deaths (birds, squirrels,
    outdoor pets, etc.).

-   Unexpected absence of insects and the scattering of wildlife.

-   Multiple serious casualties all arriving from a similar setting or
    same site.

-   Nausea, vomiting, disorientation, muscle twitching, pinpoint pupils,
    difficulty breathing or seizures.

-   Report of unusual, unexplained liquid, spray or vapor.

-   Droplets with a very oily film detected in the air or from an air
    conditioning/heating air ventilation system.

-   Reports of unexplained odors (e.g., garlic, horseradish, geraniums,
    freshly mowed hay).

-   Low clouds or fogs unrelated to the weather.

-   Suspicious containers, spraying devices or leaking packages.

In this setting, the agent in question will probably be unknown or at
best unverified, the number of casualties much greater and the degree of
panic or chaos extremely high. Patients may be arriving in a state of
fear and panic via self-transport means without previous
decontamination. Attention must immediately be given to facility
security and lockdown, establishing the facility Emergency Operations
Center (EOC) and rapid, safe deployment of the hospital decontamination
team. Patient triage should be based on signs and symptoms at
presentation and reassessed frequently. *(See sample SOP, Triage During
a Mass Casualty Incident, Section 6 in the Emergency Management Program
Guidebook.)* Antidotes for any anticipated, high-risk events should be
available whenever possible. Activation of the emergency Pharmacy Cache
supplies may be required in such an event. *(See sample VHA
Pharmaceutical Cache SOP, Section 6 in the Emergency Management Program
Guidebook.)*

It is important to remember that in either the accidental or intentional
release of a chemical agent, conditions may change significantly over
time; and any plan developed should allow flexibility, as any of the
following may change due to weather conditions:

-   Plume danger zone.

-   Evacuation routes.

-   Controlled safe zones of hospital decontamination operations, as
    directed by the Safety Officer and EOC.

-   Routes of approach to the hospital decontamination unit.

-   Routes of approach to the alternate Emergency Room for
    non-contaminated patients with non-event related emergencies (chest
    pain, gunshot wound, broken bones, etc.).

-   Plan for receipt and distribution of critical supplies (water,
    medical supplies, etc.).

2\. ***Purpose***. The purpose of the Chemical Event and Terrorism
Readiness (ChETR) Plan is to describe how the VA Medical Center will
respond to chemical disaster events. This Plan addresses policy
requirements, assumptions and processes for a VA Medical Center-wide
coordinated response that focuses on safety of the work environment for
the protection of our patients, employees, facility and community.

3\. ***Scope***. This Chemical Event and Terrorism Readiness (ChETR)
Plan applies to all employees, ensures compliance with The Joint
Commission (TJC) and OSHA requirements, and implements the VA Medical
Center's strategy for responding to all potential chemical related
emergency events in the hospital receiver role. It is designed to
respond and protect the well being of patients, employees and all
occupants within the VAMC, protect the physical infrastructure and allow
for business continuity to the fullest extent possible.

Specific sample Standard Operating Procedures (SOPs) based on specific
threats thought most likely to be faced can be found in Section 6 of the
Emergency Management Program Guidebook. These SOPs, developed as a
result of the Hazard Vulnerability Analysis (HVA), define the
mitigation, preparedness, response and recovery efforts necessary to
minimize the potential adverse impact from chemical events most likely
to be encountered.

4\. ***Policy***. In the event of a chemical disaster, the VA Medical
Center will implement the Chemical Event and Terrorism Readiness (ChETR)
Plan to make certain the necessary services are provided to ensure a
safe environment for all occupants. The VA Medical Center will work
closely with the community to ensure effective interaction during
response and recovery.

5\. ***Notification Processes and Contact Information***. Healthcare
facilities may be the initial site of recognition and response to
external chemical events, particularly if physically located near the
site of the spill or release. Notification should immediately include
the facility hospital Director, healthcare providers, Engineering,
hospital Safety Officer, Clinical Laboratory Director, Environmental
Management Service chief and other clinical and administrative service
chiefs.

If appropriate, the Office of the Director will activate the Emergency
Operations Center (EOC) and will coordinate with all internal services,
Network Director, Department of Health, FBI field office, local police,
CDC and medical emergency services.

a\. Internal Facility Contact Numbers:

Hospital Director \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Chief of Staff \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Safety Officer \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Clinical Laboratory \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Engineering \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Environmental Management \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Nutrition and Food Service \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

b\. External Contacts:

Network Director \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Area Emergency Manager \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Health Department \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Local FBI Field Office\* \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\*(See Attachment A - FBI Field Office Contact Numbers.)

Local Medical Facility Contacts:

University Hospital \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Hospital A \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Hospital B \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Hospital C \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Hospital D \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Initial Notification to Network (VISN) Director should include:

-   Facility name and location of event or impact area (e.g., site of
    the release or spill).

-   Name and position of reporting official.

-   Incident Command station phone number and ICS manager's name.

-   Short Situation Report (to include type of chemical event, clinical
    symptoms and level of diagnostic certainty, e.g., suspected agents,
    presumptive diagnosis or confirmed agent).

-   Chronological order of events, to include number of patients
    received to date.

-   Immediate and projected short-term resource needs.

-   Status of Public Health Service notification.

-   Summary of all other agencies or facilities to be notified.

6\. ***United Nations Hazard Classes***. Consideration of the various
types of chemical agent classes, the types of compounds within each
class and the potential clinical effects of exposure are very helpful.
Table 1 below lists the chemical agents as outlined by the United
Nations Hazard Class system that are linked to the Department of
Transportation (DOT) hazardous materials listings. Chemicals can be
referred to using the specific chemical name or United Nations Number
using the UN/NA/PIN (United Nations/North American/PIN) system. Caution
must be noted that multiple chemicals may have the same United Nations
number! It is always best to explore potential chemical agents and their
effects by specific chemical names whenever possible. Each of the
chemical classes noted in the Table below may result in significant
injury to the cardiovascular system, central nervous system, respiratory
system, gastrointestinal system, skin and eyes. Special considerations
are noted whenever a generalized caution or clinical issue/impact should
be remembered.

**Table 1 - United Nations Hazard Classes**

+------+-----------+-------------------+-------------------------------+
| **Un | **Agent** | **Examples**      | Special Considerations        |
| ited |           |                   |                               |
| Nat  |           |                   |                               |
| ions |           |                   |                               |
| Cla  |           |                   |                               |
| ss** |           |                   |                               |
+------+-----------+-------------------+-------------------------------+
| 1    | E         | TNT, dynamite     | Methemoglobinemia;            |
|      | xplosives |                   |                               |
|      |           |                   | Blast Trauma (see sample      |
|      |           |                   | trauma response plan and      |
|      |           |                   | SOPs).                        |
+------+-----------+-------------------+-------------------------------+
| 2.1  | Flammable | Butane, propane,  | BLEVE potential at site of    |
|      | Gases     | acetylene,        | spill/release; expect burn    |
|      |           | hydrogen          | and trauma.                   |
+------+-----------+-------------------+-------------------------------+
| 2.2  | Non-      | Nitrogen, helium, | BLEVE potential at site of    |
|      | flammable | xenon, nitrogen   | spill/release; expect burn    |
|      | Gases     | CO2               | and trauma.                   |
+------+-----------+-------------------+-------------------------------+
| 3    | Co        | Brake fluid,      | Avoid epinephrine and beta    |
|      | mbustible | camphor, glycol   | agonists due to risk of       |
|      | and       | ethers, benzene,  | Ventricular fibrillation.     |
|      | flammable | gasoline, acetone |                               |
|      | liquids   |                   |                               |
+------+-----------+-------------------+-------------------------------+
| 4    | Flammable | Phosphorus,       | Caution: Brush particles away |
|      | solids    | lithium,          | from skin in dry setting;     |
|      |           | potassium,        | then decon patients with      |
|      |           | magnesium,        | copious amounts of water. If  |
|      |           | titanium, calcium | water reactive agents are     |
|      |           | resinate          | embedded in the skin do       |
|      |           |                   | [not]{.underline} apply water |
|      |           |                   | due to explosion risk. Cover  |
|      |           |                   | area with mineral oil, and    |
|      |           |                   | transport for surgical        |
|      |           |                   | debridement. If phosphorus is |
|      |           |                   | embedded, do                  |
|      |           |                   | [not]{.underline} apply       |
|      |           |                   | mineral oil as it promotes    |
|      |           |                   | dermal absorption.            |
+------+-----------+-------------------+-------------------------------+
| 5.1  | Oxidizers | Calcium chloride; | Agents are corrosive and may  |
|      |           | lithium peroxide  | be extremely sensitive to     |
|      |           |                   | heat and shock.               |
|      |           |                   | Life-threatening pulmonary    |
|      |           |                   | edema, circulatory collapse   |
|      |           |                   | and laryngeal edema.          |
+------+-----------+-------------------+-------------------------------+
| 5.2  | Organic   | Benzoyl peroxide, | Agents are corrosive and may  |
|      | Peroxides | peracetic acid,   | be extremely sensitive to     |
|      |           | methyl ethyl      | heat and shock.               |
|      |           | ketone peroxide   | Life-threatening pulmonary    |
|      |           |                   | edema, circulatory collapse   |
|      |           |                   | and laryngeal edema.          |
+------+-----------+-------------------+-------------------------------+
| 6    | I         | Tear gas, riot    | May see significant           |
|      | rritating | control agents,   | respiratory tract symptoms;   |
|      | materials | mace              | most mild exposures only      |
|      |           |                   | require supportive measures.  |
+------+-----------+-------------------+-------------------------------+
| 2    | Poisons A | Cyanide, arsenic, | CVS and respiratory collapse  |
| and  | and B     | phosgene,         | risk; some cause severe CNS   |
| 6    |           | pesticides,       | depression; airway and        |
|      |           | methyl bromide,   | circulatory and seizure       |
|      |           | aniline           | control essential. Some may   |
|      |           |                   | have specific antidotes       |
|      |           |                   | (Cyanide and pesticides).     |
+------+-----------+-------------------+-------------------------------+
| 6    | Et        | Viable            | Symptomatic and supportive    |
|      | iological | micro-organisms   | care should be begun          |
|      | Agents    | (anthrax, HIV,    | immediately. Always use       |
|      |           | tetanus,          | Standard Precautions as       |
|      |           | botulinum, etc.)  | minimum PPE level. See        |
|      |           |                   | Biologic Event and Terrorism  |
|      |           |                   | Response Plan and SOPs.       |
+------+-----------+-------------------+-------------------------------+
| 7    | Rad       | Plutonium,        | Exposure versus contamination |
|      | ioactives | cobalt, etc.      | distinction critical. See     |
|      | I, II and |                   | Radiological Event and        |
|      | III       |                   | Terrorism Response plan and   |
|      |           |                   | SOPs.                         |
+------+-----------+-------------------+-------------------------------+
| 8    | C         | Strong acids and  | Do not attempt to neutralize  |
|      | orrosives | bases with pH     | products, as risk of          |
|      |           | less than 2.5 or  | exothermic reactions (water + |
|      |           | greater than      | agent = HEAT) exists. Do not  |
|      |           | 12.5. HCl, NaOH,  | use emetics; protect airway;  |
|      |           | potash            | consult Safety officer        |
|      |           |                   | regarding PPE.                |
+------+-----------+-------------------+-------------------------------+

> CNS = Central Nervous System; BLEVE = Boiling Liquid Expanding Vapor
> Explosion (BLEVE) potential; HIV = Human Immunodeficiency Virus.

7\. ***Pre-planning Considerations for Chemical Events***. The best
approach for an ongoing response plan for a chemical event requiring
hospital based first receiver activities is to use a multidisciplinary
team for planning, team development, ongoing refinement and assessment
through drills and exercises. Utilize the expertise of employees with
the following skills whenever possible:

-   Safety Officer

-   Industrial Hygienist and/or Chemist

-   Firefighters

-   Decontamination training (especially those with military experience)

-   Police and Security

-   Engineering

-   Nursing Service and Providers

-   Emergency Room Physician

-   Public Health Specialist

-   Environmental Management Services

-   Public Affairs officer

a\. *Facility Lockdown*. It is important that the established plan allow
for immediate facility lockdown and immediate initiation of emergency
hospital decontamination procedures whenever a potential event is
suspected. *(See sample SOP on Lockdown - Heightened Security
Procedures, Section 6 in the Emergency Management Program Guidebook.)*
Awaiting a hierarchy of approval after complete confirmation that an
event has occurred only adds to the risk that panicked victims rushing
through hospital doors seeking care will contaminate the medical
facility. If available, video camera access to the area immediately
surrounding the Emergency Room entrance door, along with an intercom
system, can help Emergency Room personnel address the fears and concerns
of arriving victims, as hospital personnel don their Level C PPE. The
initial victims arriving at the medical facility will generally be the
least injured and can be coached to walk through self-showering (or, if
a fixed facility is available, full self-decontamination), while the
Decontamination Team is gearing up to exit the facility and assist these
and other victims who will be seeking assistance.

b\. *Secondary Events*. Extreme caution should always be taken by the
Decontamination Team, as potential for secondary events may not only
occur at the site of the initial release, but at anticipated response
facilities, such as major hospitals. Secondary events may include bombs,
additional chemicals, radiological materials or biologic agents. It is a
good idea to include the hand-held Geiger counters as a standard part of
operational equipment, just in case a radiological element has been used
in the intentional terrorist event.

c\. *Police and Security*. Police and Security assistance is essential
in maintaining facility lockdown and a safe perimeter around the Medical
Center. Consideration can be given to developing an emergency security
personnel network (ESPN) within the hospital personnel pool system with
people who can be trained by facility Police to assist in focused tasks
such as door lockdown maintenance and corridor route control within the
facility. This allows the Police to be at the front-line of the event
with the Decontamination Team, maintaining order and outdoor perimeter
safety. As outlined by OSHA, Police who are dressed and outdoors in
Level C gear, require Operations Level training on an ongoing basis.

d\. *Interlinking Response Plans and SOPs*. The Chemical Event and
Terrorism Response Plan will interlink often with other response plans
and SOPs in the overall VA Medical Center Emergency Management Plan.
These will be referenced whenever possible and should be referred to for
more detailed information. These include response plans and SOPs for:
Healthcare First Receiver Decontamination; Pharmaceutical Cache;
Biologic Events; Radiological Events; Mass Casualty Evacuations;
Disaster Triage; and Trauma Management.

e\. *Syndrome-Based Criteria*. Rapid response to a chemical event
requires prompt identification of its onset and rapid patient triage and
treatment. In the event of a chemical injury, the difference of minutes
to decontamination and treatment can make tremendous clinical impact.
Hospital first receivers and VA Medical Center medical personnel must
expect that treatment will begin based on symptoms of the patients
presenting or being brought in from the site of the spill or release.
Although laboratory testing is available to confirm the presence of many
agents, these are generally not available in the hospital clinical
laboratory setting. Table 2 below may serve as a quick reference of
potential presentations, outlining predominant symptoms or syndromes and
agents for consideration. This listing is [not]{.underline} intended to
be all-inclusive, but a generalized grouping of some of the most likely
presentations and most likely agents for considerations.

**Table 2 - Clinical Syndromes in a Chemical Event**

+-------------------------------+--------------------------------------+
| **Syndrome**                  | **Potential Agents to Consider**     |
+===============================+======================================+
| Skin rash, blistering and/or  | Lewisite; Phosgene oxime; anhydrous  |
| burns with immediate pain,    | ammonium; hydrogen chloride;         |
| redness and blistering within | hydrogen fluoride; hydrogen sulfide. |
| seconds to minutes.           |                                      |
+-------------------------------+--------------------------------------+
| Skin rash, blistering and/or  | Sulfur Mustard; Nitrogen Mustard;    |
| burns with latency period     | trichothecene (T-2 mycotoxins).      |
| (hours to sometimes 2 days)   |                                      |
| prior to symptoms, redness    |                                      |
| and/or blistering.            |                                      |
+-------------------------------+--------------------------------------+
| Predominant pulmonary         | Pulmonary agents (phosgene, PFIB,    |
| symptoms developing rapidly   | diphosgene, chlorine, oxides);       |
| (seconds to minutes after     | Lewisite; Phosgene oxime; anhydrous  |
| exposure).                    | ammonium; sulfur dioxide; hydrogen   |
|                               | chloride; hydrogen fluoride;         |
|                               | hydrogen sulfide; T-2 mycotoxins.    |
+-------------------------------+--------------------------------------+
| Predominant pulmonary         | Phosgene; Mustard agents; Ricin;     |
| symptoms developing more      | Abrin; T-2 mycotoxins;               |
| slowly (hours to days after   | Staphylococcal enterotoxin B (SEB).  |
| exposure).                    |                                      |
+-------------------------------+--------------------------------------+
| Seizures and/or sudden coma   | 1\. Nerve agents: Tabin \[GA\];      |
| (symptoms may develop within  | Sarin \[GB\]; Soman \[GD\] and VX.   |
| seconds to minutes; sometimes | (Mixed glandular secretions and      |
| a few hours if mild exposure  | skeletal muscle fasciculation:       |
| by dermal route only).        | Atropine and 2-Pralodoxime chloride  |
|                               | antidotes!).                         |
|                               |                                      |
|                               | 2\. Organophosphates (Mixed          |
|                               | glandular secretions and skeletal    |
|                               | muscle fasciculation: Atropine and   |
|                               | 2-Pralodoxime chloride antidotes!).  |
|                               |                                      |
|                               | 3\. Blood agents: hydrogen cyanide;  |
|                               | cyanogens (Flushing with excessive   |
|                               | 'pinkness,' almond odor may be noted |
|                               | by some; remember cyanide antidote   |
|                               | kits!).                              |
|                               |                                      |
|                               | 4\. Hydrogen sulfide (gasping        |
|                               | breaths followed by collapse, coma   |
|                               | and seizures).                       |
+-------------------------------+--------------------------------------+
| Acute Non-immune Hemolytic    | Arsine (heavy gas with garlic like   |
| Anemia (anemia develops       | or 'fishy' odor noted by those       |
| within 2- 24 hours of         | exposed). Used in industry           |
| exposure).                    | (especially in development of        |
|                               | computer chips and fiber optic       |
|                               | equipment).                          |
+-------------------------------+--------------------------------------+

f\. *Matrix-Based System for Agent Categorization*. Another system that
can be used to place an unknown agent into a specific category is the
Chemical Agent Indicator Matrix, (based on example in Jane's Chem-Bio
Handbook, 2^nd^ edition, pp.20-23). This system is designed specifically
around the chemical warfare agents, so this must be remembered if this
system is used by emergency medical personnel. In this system all
chemical warfare agents are grouped into five categories as follows:

> A = Nerve Agents
>
> B = Blister Agents
>
> C = Cyanide
>
> D = Pulmonary Agents
>
> E = Riot Control Agents

**Table 3 - Chemical Agent Indicator Matrix**

(**A**=Nerve Agent; **B**=Blister Agent; **C**=Cyanide; **D**=Pulmonary
Agent; **E**=Riot Control Agent)

  --------------------------------------------------------------------------------------------
  **Physical Indicator Noted in Examination**      **A**    **B**   **C**    **D**    **E**
  ------------------------------------------------ -------- ------- -------- -------- --------
  **Appearance**                                                                      

  Prostration                                      X        \-      X        \-       \-

  Twitching                                        X        \-      X        \-       \-

  Convulsions                                      X        \-      X        \-       \-

  Coma                                             X        \-      X        \-       \-

  Bleeding from mouth                              X        \-      X        \-       \-

  Coughing                                         X        \-      X        X        X

  Sneezing                                         X        \-      X        \-       X

  Vomiting                                         X        X       X        \-       X

  Fasciculations (muscle twitching)                X        \-      \-       \-       \-

  **Skin**                                                                            

  Cyanosis (bluing of skin)                        X        \-      X        \-       \-

  Gray area of dead skin                           \-       X       \-       \-       \-

  Pain, irritation                                 \-       X       X        X        X

  Clammy                                           X        \-      X        \-       \-

  Sweating, localized or generalized               X        \-      \-       \-       \-

  **Eyes**                                                                            

  Small pupils                                     X        \-      \-       \-       \-

  Normal, large pupils                             X        X       X        X        X

  Involuntary closing                              \-       \-      X        \-       X

  Tearing                                          X        \-      X        X        X

  Burning, irritation                              \-       X       X        X        X

  Headache, pain around eyes                       X        \-      \-       \-       \-

  Dim vision                                       X        \-      \-       \-       \-

  Blurred vision                                   X        \-      \-       \-       \-

  Burning pain in eyes                             \-       X       X        X        X

  Redness                                          X        \-      \-       \-       X

  **Respiratory**                                                                     

  Coughing                                         X        \-      X        X        X

  Runny nose                                       X        \-      X        X        X

  Tight chest (shortness of breath)                X        \-      X        X        X

  Burning, irritation of nose                      \-       X       X        X        X

  **Cardiovascular**                                                                  

  Slow heart rate                                  X        \-      \-       \-       \-

  Fast heart rate                                  X        \-      X        X        X

  **Digestive System**                                                                

  Defecation/diarrhea                              X        \-      X        \-       \-

  Nausea                                           X        X       X        \-       X

  **TOTAL**                                                                           

  Total possible indicators in each agent group    **26**   **8**   **23**   **11**   **16**
  (A, B, C, D, E)                                                                     
  --------------------------------------------------------------------------------------------

X = possible finding within agent group; - = not expected for agent.
Note: Circle the symptoms noted, and tally up each column to determine
most likely chemical warfare agent group, based on comparison to
expected symptoms.

g\. *Special Considerations for Mission Critical Engineering Systems*.
In the setting of any chemical event, it is essential to involve
Facility Engineering personnel, the Safety Officer and the Industrial
Hygienist in the patient management planning processes in order to
ensure maintenance of a safe facility environment for both hospital
personnel and our patients. Areas within the expertise of Engineering
that must be included in the planning process include:

-   Heating, Ventilation and Air-Conditioning (HVAC) System management.

-   Steam Distribution Systems.

-   Room and Hood exhaust integrity.

-   Water Delivery Systems.

-   Water Conditioning/Drinkability.

-   Critical Supplies and Equipment Resources.

-   Internal Transportation Systems (Pneumatic tubes, elevators, robotic
    systems, food service transportation needs).

-   External Transportation Systems (Vans, etc.).

-   Medical Gases maintenance.

-   Electrical distribution.

-   Communications.

Involving Engineering in the planning and disaster management process
will ensure that mission critical engineering systems essential to
maintaining facility integrity will be properly monitored and preserved.

8\. ***Post Exposure Management***.

a\. *Decontamination of Patients and Environment*. In an event in which
patients are grossly contaminated with an unknown substance or a known
chemical compound, standard hospital receiver decontamination protocols
should be implemented. *(See sample Healthcare First Receiver
Decontamination Readiness Plan, Section 7, and sample Healthcare First
Receiver Decontamination SOP, Section 6 in the Emergency Management
Program Guidebook.)* Any unknown substance gross contamination could
potentially represent a biologic agent, chemical agent with delayed
symptoms or radiological agent. Potentially harmful practices, such as
bathing patients with bleach solutions, are unnecessary and should be
avoided. Clean water, saline solution or commercial ophthalmic solutions
are recommended for rinsing eyes. VAMC personnel will be stationed at
both the male and female ambulatory self-decontamination sites to assist
in any way, and to ensure that decontamination proceeds in an organized,
calm fashion. Designated VAMC employees will escort all patients who
have showered and changed to a large secure designated waiting area.
*(See sample Healthcare First Receiver Decontamination Readiness Plan,
Section 7; and sample Healthcare First Receiver Decontamination SOP,
Section 6 in the Emergency Management Program Guidebook.)* The FBI may
require collection of exposed clothing and other potential evidence for
submission to FBI or Department of Defense (DoD) laboratories to assist
in exposure investigations. *(See sample Chain of Custody Readiness Plan
in Section 7 of the Emergency Management Program Guidebook.)* Plans for
containment of contaminated run-off should be made jointly with
Engineering, Safety and local authorities.

b\. *Triage and Management of Large Scale Exposures and Suspected
Exposures*. In the event of a large-scale release, the processes for
triage, safe housing and medical care for potentially large numbers of
affected individuals will follow the Emergency Preparedness Mass
Casualty Plan. Triage and management planning for large-scale events may
include:

-   Establishing networks of communication and lines of authority;
    coordinating on-site care.

-   Establishing networks of communication internally to provide
    continuous staff education and status reports, and to maximize
    education while minimizing rumor, fear and panic.

-   Planning for cancellation of non-emergency services and procedures.

-   Planning with Nutrition and Food Service for anticipated needs.

-   Planning with Environmental Management Services to ensure
    appropriate EMS staff receive education and are aware of procedures
    to follow during a chemical event to ensure their safety.

-   Identifying sources able to supply available vaccines, immune
    globulin, antibiotics, and anti-toxin (with assistance from local
    and state public health departments).

-   Planning for the efficient evaluation and discharge of patients.

-   Developing discharge instructions for patients determined to be
    non-contagious or in need of additional on-site care, including
    details regarding if and when they should return for care or if they
    should seek medical follow-up.

-   Determining availability and sources for additional medical
    equipment and supplies (e.g., ventilators) that may be needed for
    urgent large-scale care.

-   Planning for the allocation or re-allocation of scarce equipment in
    the event of a large-scale event (e.g., duration of ventilator
    support of terminally afflicted individuals).

-   Coordinating with Pathology service; identifying the institution's
    ability to manage a sudden increase in the number of cadavers on
    site.

c\. *Psychological Aspects of a Chemical Terrorism Event*. Following an
accidental or intentional chemical terrorism event, fear and panic can
be expected from patients, hospital personnel and members of the
community. Psychological responses following these events may include
horror, anger, panic, unrealistic concerns about contamination,
paranoia, social isolation and demoralization. Mental health support
personnel (e.g., psychiatrists, psychologists, social workers, clergy
and volunteer groups) will assist in collaboration efforts to address
the immediate and subsequent mental health needs of the patients,
hospital personnel and family members. The hospital Director and Public
Affairs Officer or their designees will coordinate with the media. The
Emergency Operations Center and medical officers will coordinate with
external Emergency Medical Services. Local, state and federal experts
may also provide assistance with communications and education needs.

When developing this plan, consideration of the following was made to
address *patient and general public* fears:

-   Minimize panic by clearly explaining risks, offering careful but
    rapid medical evaluation/treatment, and avoiding unnecessary
    isolation.

-   Treat anxiety in unexposed persons who are experiencing somatic
    symptoms (e.g., with reassurance, or diazepam-like anxiolytics as
    indicated for acute relief of those who do not respond to
    reassurance).

When developing this plan, consideration of the following was made to
address *healthcare worker* fears:

-   Provide chemical event (accidental or intentional terrorist events)
    education, including frank discussions of potential risks and plans
    for protecting healthcare providers.

-   Invite active, voluntary involvement in the chemical event and
    terrorism readiness planning process.

-   Encourage participation in disaster drills.

-   Fearful or anxious healthcare workers may benefit from their usual
    sources of social support or by being asked to fulfill a useful role
    (e.g., as a volunteer at the triage site).

9\. ***Laboratory Support and Confirmation***. VA Medical Center
Pathology and Laboratory Medicine Service has a full service clinical
laboratory. The laboratory may participate as a member of the Centers
for Disease Control and Prevention (CDC) Laboratory Response Network
(LRN) and enjoy the benefit of standardized training sessions on
collection of specimens and transport of specimens to the CDC in the
event of a chemical disaster. Specimens for transport will be packaged
in accordance with Department of Transportation (DOT) guidelines for
shipping of hazardous materials. VA Medical Centers work with county,
state and federal public health service representatives to tailor
diagnostic strategies to specific events. Currently the Bioterrorism
Emergency Number at CDC is at the Emergency Response Office, National
Center for Environmental Health (NCEH), 770-488-7100.

a\. *Obtaining Diagnostic Samples*. For specific recommendations on
diagnostic sampling for each type agent, contact the local Public Health
service laboratory. The Laboratory Response Network chemical event
protocol emphasizes the types of blood and urine samples to send, need
for "background" empty tubes and containers for each sample, consent and
chain-of-custody requirements and forms and shipping requirements.
Sample collection should be performed in accordance with Standard
Precautions. The CDC website for Laboratory Protocols and the Laboratory
Response Network Guidebook is helpful when dealing with specific agents
or syndromes. See sample Chain-of-Custody Readiness Plan (Section 7,
Emergency Management Program Guidebook) to ensure compliance with
chain-of-custody requirements from the point of specimen collection. The
Laboratory Response Network guidebook provided by the Public Health
Service Laboratory to each local hospital also includes shipping
information and a PHS Chain-of-Custody form for all samples submitted
for evaluation during a chemical disaster event.

b\. *Transport Requirements*. Specimen packaging and transport will be
coordinated with local and state health departments, the Laboratory
Response Network and the FBI. Packaging materials and transport media
will be chosen by VAMC clinical laboratory in collaboration with these
entities. For specific instructions, contact the Bioterrorism Emergency
Number at the CDC Emergency Response Office, 770-488-7100 or the state
Public Health Laboratory, Bioterrorism Preparedness Coordinator
[\_\_\_\_\_\_(name)\_\_\_\_\_\_\_]{.underline} at [(phone)]{.underline}
.

c\. *CDC Laboratory Response Network*. The Centers for Disease Control
and Prevention established the Laboratory Response Network (LRN) per
Presidential Decision Directive 39, dated 1995. This Directive outlined
national anti-terrorism policies and assigned specific missions to
federal departments and agencies. Through a collaborative effort
involving LRN founding partners, the Federal Bureau of Investigation and
the Association of Public Health Laboratories, the LRN became
operational in August 1999. Its objective was to ensure an effective
laboratory response to bioterrorism by helping to improve the Nation's
public health laboratory infrastructure, which had limited ability to
respond to bioterrorism.

Today, the LRN is charged with the task of maintaining an integrated
network of local public health, federal, military and international
laboratories that can respond to both bioterrorism and chemical
terrorism. The LRN is a unique asset in the nation's growing
preparedness for biological and chemical terrorism. The linking of state
and local public health laboratories, veterinary, agriculture, military
and water-and food-testing laboratories is unprecedented.

The Laboratory Response Network (LRN) and its partners will maintain an
integrated national and international network of laboratories that are
fully equipped to respond quickly to acts of chemical or biological
terrorism, emerging infectious diseases and other public health threats
and emergencies.

d\. *Tissue Handling and Post-Mortem Care*. Pathology and Laboratory
Medicine Service should be informed of any potential chemical
contamination prior to submitting specimens for examination or bodies
for autopsy or disposition. Pathology and Laboratory Medicine Service
will use standard protocols for handling potentially contaminated bodies
and tissues. Post-mortem examinations will be coordinated with the State
Medical Examiner or coroner. In the event of a terrorist event-related
death, all tissues and reports become critical evidence and will be
handled in accordance with state and federal law. Instructions will be
given to funeral directors in cooperation with the Medical Examiners
office before any bodies or remains are released.

10\. ***Patient, Visitor and Public Information***. Clear, consistent,
understandable information will be provided (e.g., via fact sheets) to
patients, visitors and the general public. Visitors may be limited at
the discretion of the hospital Director and the EOC. Crowd control will
be the responsibility of VAMC Police and Security who may be assisted by
VAMC volunteers, if appropriately trained and approved by Police and
Security. Military personnel may also be utilized in response to mass
casualties, as designated by state and federal leaders, and approved by
the Department of Defense (DoD).

The Office of the Director for Public Affairs personnel will disseminate
information to the media. Failure to provide a public forum for
information exchange may increase anxiety and misunderstanding,
increasing fear among individuals who attribute non-specific symptoms to
exposure to the bioterrorism agent.

11\. ***Drills and Exercises***. The reality of facing a community-wide,
region-wide or statewide chemical disaster is a daunting consideration,
regardless of whether it is an accident or an intentional chemical
release. The latter would, of course, instill a greater degree of fear
and urgency. No hospital expects to be able to completely handle such an
event without difficulty. The more training and education provided, the
more comfortable healthcare providers feel about dealing with such an
event.

Knowledge without practice is a fading process bound for failure. In
order to ensure constant readiness, drills and exercises should be
performed often and must present increasingly challenging situations as
expertise and comfort levels rise. (See Section 9, Education, Training
and Exercises, Emergency Management Program Guidebook.) With any plan,
it is important to actually practice the things that employees are least
familiar with \-- things they don't do in their day-to-day employment,
such as:

-   Donning and Doffing of PPE.

-   Practicing lifting techniques using litters and carts.

-   Practicing washing techniques (head to toe; front to back).

-   Utilizing emergency communication devices (head sets; hand-held
    radios, etc.).

-   Utilizing emergency hand-signals, for those in PPE who do not have
    radios.

-   Collecting materials for tracking of evidence within a crime scene.

After each drill, tabletop exercise or practice sessions analyze:

-   What was done best?

-   What could have been done better?

-   What were the major problems?

-   What can we do to improve the process?

-   When can we next test our capabilities and try these improvements to
    see how well they actually work?

**Scenario 1:** You have received a call from Emergency Medical System
(EMS) personnel that an 18-wheeler has wrecked, and is now leaking
phosgene oxime along a highly populated area. You are cautioned to
prepare to receive casualties in about 30-35 minutes. Estimated injured
at this point are 10, and patients will be distributed to all responding
hospitals (expect 1-3 casualties per facility at this point).

**Considerations:** You know the agent, and you have time to quickly
look it up and refresh the Emergency Department personnel on expected
findings. The numbers are small, and patients are being distributed in
an organized fashion throughout the city. Phosgene oxime is a pulmonary
agent, so symptomatic respiratory support is essential. Have personnel
for intubation assistance and ventilator support ready if needed. You
should activate the Hospital Decontamination Team; you do not know for
sure that other area residents have not been exposed, and they could be
on the way to your facility for treatment. Although phosgene oxime is
primarily a pulmonary agent, any contamination of the casualties could
place your hospital employees at risk of secondary exposure. Chemical
should be removed before patients enter the facility. Those being
transported by ambulance from the scene have been thoroughly
decontaminated.

**Scenario 2:** An accident has occurred at the nearby chemical
stockpile arsenal, and you are the responding hospital. Two workers
exposed to sarin are being transported; they have both received two
Mark-1 injections and are in stable condition.

**Considerations:** The numbers are small, and you know the agent and
the estimated level of exposure (One Mark-1 = Mild exposure; Two Mark-1s
= Moderate exposure; Three Mark-1s and Diazepam = severe exposure). Have
antidote (Mark-1s or injectable atropine and 2-PamCl) ready should
symptoms be persistent upon arrival of casualties. Workers have been
thoroughly decontaminated at the arsenal by personnel well-versed in
accidents of this type. Remember: Vapor exposure peaks quickly (within 1
hour) and subsides quickly; liquid exposures may be delayed and the peak
may not occur for up to 24 hours.

**Scenario 3:** An explosion at a nearby chemical facility has caused
the release of agents, as yet undetermined. The Sara Title III report
notes that the plant contains predominately corrosives and a limited
supply of oxidizers. Emergency personnel at the scene have been unable
to specify which tanks have been affected and what chemical or mix of
chemicals has been released. There were 34 workers in the plant at the
time of the explosion, and all have been decontaminated at the scene and
are in transport to local medical facilities.

**Considerations:** You don't know what the agents are here. More
importantly, there is the potential of mixed agents with unknown new
reactants formed by the combination of these agents. Prepare for contact
cautions and respiratory support. Decontamination is essential. Activate
Hospital Decontamination Team immediately to assist in receipt of
patients and decontamination of anyone self-presenting. If the
decontamination status is unknown, the patients should be run through
the hospital decontamination procedure. This is to ensure protection of
the medical facility, employees and patients.

**Scenario 4:** Excited football fans have gathered in the open-air
stadium for a major season-end championship game. Early in the game a
plane flew overhead and just seconds later, spectators noticed a fine
mist of liquid material. Emergency first responders are on the scene and
have organized a decontamination system; however, crowd control is
impossible and people are scattering quickly, leaving the scene and
running to the nearest medical facilities. Estimated attendance at the
game is 38,000. There are 10 hospitals in the nearby area, and the
closest hospitals are the University, the VA Medical Center and Baptist
Hospital. EMS personnel report predominately panic, with no localized
symptoms at this moment.

**Considerations:** You don't know what the agent is or if there really
is an agent involved. This could be water used as a hoax to cause mass
panic and disruption. Think, however, of agents with a known delay
period, such as mustard agents. This could be mustard. Real or hoax, you
will not know for sure for sometime. Activate Hospital Decontamination
Team immediately and prepare for a large ongoing response. Facility
lockdown and perimeter control by VA Medical Center Police is critical
to maintaining safety of facility.