Hospital CBRN Defence — Threat of Chemical, Biological, Radioactive and Nuclear Weapons

This arti­cle is pub­lished with the kind per­mis­sion of “Defence and Secu­ri­ty Alert (DSA) Mag­a­zine” New Delhi-India

One of the great­est dis­as­ter sce­nar­ios is the use of WMDs by non-state actors. India is enhanc­ing its com­mit­ment to nuclear ener­gy. These reac­tors are also poten­tial tar­gets for mass casu­al­ty ter­ror strikes. The recent Tsuna­mi in Japan led to a nuclear melt­down on an unprece­dent­ed scale. CBRN (Chem­i­cal, Bio­log­i­cal, Radioac­tive and Nuclear Weapons) ter­ror­ism or cat­a­stro­phes with a radi­o­log­i­cal dimen­sion trig­gered by nat­ur­al or man-made dis­as­ters are an even­tu­al­i­ty that we must be well pre­pared for in this coun­try. The recent Del­hi High Court blast also high­light­ed the need for casu­al­ty man­age­ment in such sce­nar­ios. A very time­ly and well writ­ten arti­cle by a Greek Brigadier Gen­er­al on CBRN response by hos­pi­tals in the event of WMD based ter­ror strike or nat­ur­al dis­as­ter. This arti­cle focus­es on hos­pi­tal CBRN pre­pared­ness in megapo­lis envi­ron­ment and com­ments on the atti­tude of state high offi­cials involved in CBRN planning. 

Megapo­lis

A megapo­lis (com­bined Greek word: mega [or mega­lo] = huge and polis = city), also known as mega­lopo­lis or megare­gion, is a clus­tered net­work of cities with a pop­u­la­tion of about 10 mil­lion or more and at least 2,000 per­sons / km2 (i.e. Del­hi has a land of 1,483 km² and a pop­u­la­tion den­si­ty of 9,296 peo­ple / km2). Mod­ern inter­linked ground trans­porta­tion cor­ri­dors, such as rail and high­way, often aid in the devel­op­ment of mega­lopolis­es. In the top-20 of most pop­u­lat­ed cities world­wide (Table 1), there are three Indi­an mega­lopolis­es — Mum­bai, Del­hi and Kolkata. 

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Hos­pi­tals as targets

Since the begin­ning of the 21st cen­tu­ry, hos­pi­tals both in peace and war were con­sid­ered as sacred areas respect­ed by adver­saries either in urban envi­ron­ment or in the oper­a­tional field. Start­ing with Cama Hos­pi­tal in the Mum­bai 2008 mul­ti­ple ter­ror­ist attacks many instances of hos­pi­tals’ attacks have been record­ed in var­i­ous coun­tries around the globe (i.e. Mil­i­tary Hos­pi­tal in Kab­ul, Afghanistan [2011], Mis­ra­ta Hos­pi­tal in Libya [2011], etc.). There­fore it is obvi­ous that hos­pi­tals rep­re­sent an attrac­tive soft tar­get for mod­ern ter­ror­ists. If by attack­ing hos­pi­tals you kill the hope for the peo­ple involved in a ter­ror­ist inci­dent then it is like killing them twice. 

CBRNE inci­dent site

In case of a real CBRN ter­ror­ist inci­dent in a megapo­lis envi­ron­ment there are two things that you must have always in mind. The first one is that plan­ning should fol­low major anthro­pocen­tric pat­terns. This means that every plan should always answer the fol­low­ing ques­tion: “What would be my per­son­al reac­tion if involved in such an incident?”

The sec­ond one refers to cer­tain sta­tis­tics that are cru­cial to remem­ber and have to do with the crowd behav­iour. In that respect it is esti­mat­ed that after the CBRN inci­dent approx­i­mate­ly 20 per cent of those involved will remain in place (dead, severe­ly wound­ed and / or con­t­a­m­i­nat­ed). The remain­ing 80 per cent will flee to all pos­si­ble direc­tions seek­ing med­ical assis­tance or if not wound­ed or con­t­a­m­i­nat­ed will go home. The third impor­tant sta­tis­tic is that the ratio of tru­ly con­t­a­m­i­nat­ed vs “wor­ried well” is 1:5. This will soon over­whelm hos­pi­tals and col­lapse even the most organ­ised and advanced med­ical sys­tems world­wide. The expe­ri­ence from Tokyo sarin release shows that 84.5 per cent of those involved went to 169 hos­pi­tals and clin­ics all over the cap­i­tal by their own means. The above num­bers stress the need to invest on hos­pi­tals’ CBRN defence instead of clas­sic “gold­en hour” first respon­ders. The lat­ter will cer­tain­ly go there but they will arrive late (due to very heavy traf­fic and big dimen­sions of decon­t­a­m­i­na­tion vehi­cles) and most prob­a­bly those who are severe­ly con­t­a­m­i­nat­ed / wound­ed would be dead. So why invest all that mon­ey on first respon­ders that will go there late instead of invest­ing on health infra­struc­ture that will sure­ly accept those escaped and have a good chance to sur­vive? No need to say that med­ical con­se­quences of CBRN agents’ release might last for decades — as is the case with Iran-Iraq chem­i­cal war casualties. 

The expe­ri­ence from Tokyo sarin release shows that 84.5 per cent of those involved went to 169 hos­pi­tals and clin­ics all over the cap­i­tal by their own means. The above num­bers stress the need to invest on hos­pi­tals’ CBRN defence instead of clas­sic “gold­en hour” first respon­ders. The lat­ter will cer­tain­ly go there but they will arrive late (due to very heavy traf­fic and big dimen­sions of decon­t­a­m­i­na­tion vehi­cles) and most prob­a­bly those who are severe­ly con­t­a­m­i­nat­ed / wound­ed would be dead

Hos­pi­tal CBRN defence

A hos­pi­tal might be very close or adja­cent to the inci­dent site or far to very far away. If very close then reac­tion time is min­i­mal if none. This means that the EMS sec­tion of the hos­pi­tal must be able to go to “red alert” with­in min­utes. This takes a lot of train­ing, spe­cialised equip­ment, mod­ern plan­ning and open mind­ed indi­vid­u­als that under­stand the nature of the event. Hos­pi­tals that are in more dis­tant areas might have enough time to pre­pare although in many instances nobody will go there no mat­ter how pre­pared they are. It is obvi­ous that all hos­pi­tals and clin­ics both pub­lic and pri­vate should be equal­ly pre­pared to accept mass CBRN casu­al­ties in case of a ter­ror­ist event. One might say that casu­al­ties should be “guid­ed” to cer­tain spe­cialised hos­pi­tals and close all those that do not have the facil­i­ties to deal with CBRN con­t­a­m­i­nat­ed vic­tims. Now ask your­self what would be your reac­tion if arriv­ing in such a hos­pi­tal with your con­t­a­m­i­nat­ed / wound­ed child and some­one was inform­ing you that it is closed and you have to go to anoth­er far away hospital …

Hos­pi­tal preparedness

The good thing with hos­pi­tal CBRN pre­pared­ness is that most of the equip­ment need­ed is already avail­able with­in the hos­pi­tal. Of course there is cer­tain addi­tion­al equip­ment that is specif­i­cal­ly made for con­t­a­m­i­nat­ed envi­ron­ments (i.e. field res­pi­ra­tor with NBC fil­ter) but apart from these the remain­ing are every day’s mate­ri­als and resources.

The impor­tant para­me­ter in hos­pi­tal defence is to keep con­t­a­m­i­na­tion away from the hos­pi­tal, work­ing med­ical per­son­nel and exist­ing patients. In that respect the CBRN Response Unit of the hos­pi­tal should be deployed out­side the hos­pi­tal; prefer­ably at the park­ing lot of the hos­pi­tal. The response unit is com­posed by sev­er­al sta­tions that facil­i­tate the arriv­ing casu­al­ties. To start with it is very impor­tant to have a fence around the hos­pi­tal. If there is no fence then the con­trol of the arriv­ing cit­i­zens would be dif­fi­cult if not impos­si­ble to con­trol. But even with a fence some­one might try to over­ride it if not will­ing to stay in line. This means that secu­ri­ty per­son­nel should be deployed as well guard­ing the inner ter­ri­to­ry of the hos­pi­tal. The usu­al secu­ri­ty per­son­nel of the hos­pi­tal it is for sure will not be able to con­tribute since they do not pos­sess the abil­i­ties, train­ing and per­son­al pro­tec­tive equip­ment to ful­fill their mis­sion in a con­t­a­m­i­nat­ed envi­ron­ment. Police sup­port is the only solu­tion available.

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In case of a real event (Fig­ure 1):

1) All casu­al­ties / vic­tims pre­sent­ing to the hos­pi­tal will enter hos­pi­tal from one and only gate.

2) All casu­al­ties / vic­tims will go through “Detec­tion Sta­tion” where if neg­a­tive they will pro­ceed and walk through a decon­t­a­m­i­na­tion solu­tion on their way to the EMS depart­ment of the hos­pi­tal. If pos­i­tive they will pro­ceed to “Triage Station”.

3) Casu­al­ties will be either able to walk or on stretch­ers. In the first case they pro­ceed to “Mass Decon­t­a­m­i­na­tion Sta­tions” for thor­ough decontamination.

4) If non-ambu­la­to­ry they will be trans­port­ed to the “Non-Ambu­la­to­ry Vic­tims Decon­t­a­m­i­na­tion Sta­tion”. When decon­t­a­m­i­na­tion is over they will be rolled to adjust­ing “First Aid Sta­tion” for pro­vi­sion of life sav­ing first aids (anti­dotes, res­pi­ra­to­ry sup­port, bleed­ing con­trol). Anti­dotes can be giv­en at the “Triage Sta­tion” as well depend­ing on the situation.

5) When vic­tims from both the “Mass Decon­t­a­m­i­na­tion Sta­tion” and “First Aid Sta­tion” are ready and “clean” they pro­ceed through the “Ver­i­fi­ca­tion Sta­tion” that con­firms the suc­cess of decon­t­a­m­i­na­tion. If neg­a­tive they end up in the main triage area of the hos­pi­tal at the “cold zone”. If pos­i­tive they have to repeat decon­t­a­m­i­na­tion process.

6) At the “Triage Sta­tion” hos­pi­tal per­son­nel will decide who needs imme­di­ate hos­pi­tal­i­sa­tion and who can go home with writ­ten instruc­tions in case a relapse evolves with­in the next few hours. One of the main tasks of the triage per­son­nel is to get rid of “wor­ried well” that rep­re­sent a func­tion­al threat to the con­ti­nu­ity of the hos­pi­tal work due to their vast numbers.

7) First respon­ders either from the hos­pi­tal or from oth­er state depart­ments and organ­i­sa­tions need to have their own decon­t­a­m­i­na­tion line. This is manda­to­ry and this line should be deployed before start­ing to accept con­t­a­m­i­nat­ed casu­al­ties. “Save the saver to oper­ate” is the main rea­son but also the rule in all CBRN operations.