EMS Operations Advance Preparation

EMS Operations Advance Preparation
Research related multimedia links for illustration purposes. Prepare an ambulance for demonstration purposes. Research state and local regulations on equipment and ambulance operation. Prepare decontamination supplies for demonstration. Invite an air medical unit. Arrange a tour of an ambulance base, an emergency department, and an ambulance repair bay.

Preparing for the Call Type 1 Ambulance Type 2 Ambulance
Class Activity: Use a standardized equipment list to check an ambulance. If an ambulance is not available, check the class equipment used for scenario work. Type 3 Ambulance Type 4 Ambulance

Ambulance Supplies and Equipment
Learn where each item is, what it is for, and when it should be used Talking Points: States and regions set requirements for necessary equipment. If an ambulance is not properly equipped, you’re only there to provide a ride to the hospital. Knowledge Application: Have students design a standardized reporting system for broken, missing, or expended equipment. Utilize this system throughout the course.

Ensuring Readiness for Service
Make sure vehicle and equipment are ready for use at beginning of every shift Talking Points: Usually the EMT assigned to be the driver completes the vehicle component check and the EMT crew leader completes the medical equipment check. Discussion Topic: Discuss the value of checking a response vehicle prior to a call. Why is it so important? Knowledge Applications: Demand respect for equipment. All practical equipment must be put away ready for its next use. Have students use a standardized list to check the classroom equipment. Build a regular expectation of preparedness. Critical Thinking: You are treating an asthma patient with supplemental oxygen. As you are applying the nonrebreather mask, you notice that the tank is just about empty. Whose responsibility is it that this tank was not changed?

Receiving & Responding to a Call
Emergency Medical Dispatcher Interrogate caller and assign priority to call Provide pre-arrival medical instructions to callers and information to crews Dispatch and coordinate EMS resources Coordinate with other public safety agencies Points to Emphasize: Interrogation of the caller, prioritization of the call, pre-arrival instructions, coordination of EMS resources, and coordination with other public safety agencies are all important responsibilities of the Emergency Medical Dispatcher. An EMD uses specific questions to obtain information about the patient prior to the arrival of EMS crews. Discussion Topics: Discuss the key roles and responsibilities of an Emergency Medical Dispatcher. Describe how EMDs might improve patient care. Class Activity: Tour a dispatch center. Listen to prearrival questions and instructions. Knowledge Activity: Work with an EMD to simulate a 911 call. Describe a situation and listen to the prearrival questions and instructions.

Operating the Ambulance
Safe operation Understand the law Use warning devices Speed and safety Escorted or multiple-vehicle responses Respond safely Points to Emphasize: Each state regulates operation of emergency vehicles. EMTs must be familiar with rules and regulations prior to driving an ambulance. EMTs should use warning devices and sirens only in true emergencies. Talking Points: A safe ambulance operator is physically fit, mentally fit, able to perform under stress, have a positive attitude and be tolerant of other drivers. All states have laws governing the operation of an emergency vehicle. These laws state that the vehicle operator must drive with due regard for the safety of others. When using the lights, you should also utilize the siren. Save the use of lights and sirens for emergencies that are life threatening in nature. Speed increases stopping distance, reducing the chance of avoiding a hazardous situation. Although not recommended, if following an emergency vehicle, maintain a safe distance and be alert to other vehicles that may not see your vehicle. Discussion Topics: Discuss the local statutes regarding emergency vehicle operation. What rules and regulations apply in your area? Describe the proper use of warning devices during emergency response. Knowledge Application: Have students research local ambulance operation policies. Consider state, regional, and service levels. Compare and contrast.

Highway Safety Keep unnecessary units and people off highway
Avoid crossovers unless turn can be completed without obstructing traffic Talking Points: The more vehicles and people on a highway, the greater the risk to responders. Avoid crossovers in traffic. It may be safer to go to the next off ramp to change directions. Class Activity: Visit an emergency vehicle driving simulator. Experience the rigors of driving in an emergency response. Knowledge Application: Have students work in small groups. Ask each group to discuss the components of a safe scene response. Have groups present their findings. Critical Thinking: You are responding to a call at a speed that you feel is safe. Dispatch radios to tell you that first responders have asked you to “expedite” your response. Your partner yells at you to “step on it.” What do you do? continued

Highway Safety Wear all PPE
VESTS Place cones/flares and reduce emergency lighting Unit placement is important Talking Points: Responders are required to wear an ANSI Class 2 Safety vest while operating on any highway. Place cones and flares upstream in traffic to warn drivers. Reduce white flashing lights as they will blind oncoming drivers. Avoid driving over debris and skid marks when parking your vehicle. Leave room for fire apparatus close to vehicle if extrication is indicated. Command vehicles should be placed downstream away from the incident. Discussion Topic: Describe key procedures for safe vehicle operation on and around a highway. Class Activity: Have a discussion about what type of situation would necessitate an emergency response. Discuss local rules and regulations. Knowledge Application: Play with trucks. Use toy trucks to simulate ambulance traffic operations. Use a tabletop to walk through a variety of driving hazards.

Transferring the Patient to the Ambulance
Teaching Time: 15 minutes Teaching Tips: Have patient-carrying devices on hand for demonstration purposes. Give students a different perspective. Ask students to play the role of the patient in packaging scenarios. Bring an ambulance to class. Review safety restraints and discuss working in the patient compartment.

Four Steps of Transferring
Select proper patient-carrying device Package patient for transfer Move patient to ambulance Load patient into ambulance Talking Points: The term packaging refers to the sequence of operations required to ready the patient to be moved and to combine the patient and the patient-carrying device into a unit ready for transfer. Skill Demonstration: Using different examples of patient transfer devices, demonstrate proper patient packaging.

Protecting the EMT EMT at greater risk in patient compartment
Make sure all equipment is secured Remain seated Wear seat belt and harness if possible Avoid unnecessary movement during response and transport Talking Points: While caring for a patient in the back of a moving ambulance, the EMT must consider safety. Avoiding unnecessary movement and wearing restraints are important steps in staying safe.

Transporting the Patient to the Hospital
Teaching Time: 15 minutes Teaching Tips: Have stretchers and an ambulance on hand. Review securing these devices properly. Load simulated patients into an ambulance. Discuss movement and positioning. Relate to previous discussions about safety. Discuss the need for patient care in the context of passenger safety.

Preparing Patient for Transport
Continue assessment Secure stretcher in place in ambulance Position and secure patient Adjust security straps Prepare for respiratory and cardiac complications Loosen constricting clothing Load personal effects Talk to the patient Points to Emphasize: Assessment and care must continue as the patient is transferred to the hospital. The EMT should position the patient and himself to maximize these capabilities. The patient must be safely secured prior to the ambulance leaving the scene. The EMT should check that the patient is properly secured to the stretcher and that the stretcher is properly secured in place before the ambulance moves. Patients should be transferred on the stretcher. EMTs should avoid transferring patients in other seats unless there are unusual circumstances. Talking Points: Transport involves more than just driving to the hospital. Discussion Topics: Describe the steps involved in properly securing a patient to a stretcher. Consider local protocols. Describe the procedure for securing a stretcher to the ambulance. Explain why the stretcher is the most appropriate place to secure a patient for transfer. Knowledge Application: Have students work in small groups. Have each group demonstrate securing a member of the group to a stretcher.

Caring for Patient En Route
Notify hospital Continue to provide emergency care as required Use safe practices during transport Compile additional patient information Point to Emphasize: The EMT who rides in the patient compartment will continue assessment and care on the way in to the hospital. Talking Points: At least one EMT must accompany the patient and be in the patient compartment during transport. Minimize the amount of movement and standing in the patient compartment while the vehicle is in motion to prevent responder injury. Discussion Topic: Discuss the continuing responsibilities of the EMT during transfer of the patient to the hospital. Knowledge Application: Use programmed patients or manikins to simulate care in the back of an ambulance. Have students practice safe assessment and care procedures.

Transferring the Patient to the Emergency Department Staff
Teaching Time: 15 minutes Teaching Tips: This is a short section, but important with regard to medical/legal issues and good patient care. Spend time to ensure that students grasp its importance. Include verbal reports and written documentation after practice scenarios. Imprint this lesson throughout the class. Teach that transfer is an important component of patient care. Keep it in the context of any other necessary intervention.

Transferring Patient to ED
Provide verbal report Transfer patient to hospital stretcher Prepare PCR Obtain release signature Points to Emphasize: Transfer of care is a crucial step, during which the primary concern must be the continuation of patient care activities. Failure to transfer care properly can be considered abandonment. Talking Points: Under no circumstances should you simply wheel a non-emergency patient into a hospital, place him in bed, and leave him. Unless providing a transfer report, you may be abandoning your patient. Discussion Topic: Describe how the concept of abandonment might apply to an improper transfer of patient care. Class Activity: Describe a patient care scenario. Have students write out the necessary elements that they would present in a verbal report. Knowledge Application: Have students give simulated verbal reports. Have the class critique the reports.

Terminating the Call Teaching Time: 25 minutes
Teaching Tips: Make post-call readiness a common theme in class. Always prepare equipment for the next use. Even though the threat of biohazard is comparatively low, practice proper decontamination procedures on equipment in the classroom. Invite a local EMT to discuss service-level call termination procedures.

Terminating the Call: At the Hospital
Clean patient compartment Prepare equipment for service Replace expendable items Exchange equipment according to local policy Make up ambulance cot Points to Emphasize: Cleaning the ambulance, replacing used supplies and equipment, and readying the ambulance stretcher are important elements that the EMT must complete while terminating a call. Knowledge Application: Tour a local EMS service. Discuss post-call procedures such as resupply and equipment decontamination.

Terminating the Call: En Route to Quarters
Radio dispatch with your status Air out ambulance if necessary for odor control Refuel ambulance Points to Emphasize: Safe ambulance operation must continue even after the call has been concluded. Refueling, cleaning, and decontaminating the ambulance are priorities in readying the unit for the next call. Knowledge Application: Review an EMS standard operating guideline for return to service. Discuss important elements.

Terminating the Call: In Quarters
Place badly contaminated linens in biohazard containers Clean equipment Disinfect non-disposable equipment Discussion Topics: Describe the necessary steps involved in properly terminating a call. Describe the priorities involved in readying an ambulance for the next call. Class Activity: Ready equipment for the next class. Treat practice equipment as you would ambulance equipment. Imprint good habits now. Knowledge Application: Using appropriate supplies, properly decontaminate EMS equipment. Critical Thinking: Improper resupply and missing equipment issues occur frequently. What might be examples of impediments to properly readying an ambulance for the next call?

Air Rescue Teaching Time: 15 minutes
Teaching Tips: Contact your local aeromedical transport service. Ask for assistance in teaching this lesson. Discuss local protocols for activation of aeromedical transport. Discuss the risks of aeromedical transport. Review crashes and describe a cost benefit analysis in choosing air transport. Tour the local aeromedical service. Review aircraft safety procedures.

When to Call for Air Rescue
Operational reasons Speeding transport to distant trauma center Medical reasons High priority patients requiring advanced care or procedures not available at local hospital Points to Emphasize: Indications for utilizing air rescue may include both operational and medical reasons. Speed of transport and specialized capabilities often make air rescue requests appropriate. EMTs should know the local air rescue resources that are available to them and the procedures for activating those resources. Discussion Topics: Describe the benefits and risks of air rescue and aeromedical transport. Discuss the decision-making process for choosing the air mode of transport. Discuss common indications for air rescue transport. Review local protocols and regulations regarding air rescue activation. Class Activity: Tour a local air rescue service. Review the aircraft and discuss safety procedures. Knowledge Application: Describe various scenarios. Have students discuss the most appropriate mode of transport. Include an air rescue cost benefit discussion. Critical Thinking: What are the risks and costs of air rescue? Discuss examples of situations in which air rescue might not be appropriate even though some indications are present.

Information to Give When Calling
Name and call-back number Agency name Nature of situation Exact location (crossroads, major landmarks) Exact location and description of landing zone Talking Points: Follow local protocols for making a call for air rescue.

Landing Zone Setting up landing zone Approaching helicopter
Point to Emphasize: An appropriate landing zone (LZ) for a helicopter should be a flat area, free of utility lines, and at least 100 feet square. The slope of an LZ should not be greater than 8 degrees. The LZ should be marked with one flare in an upwind position. Talking Points: Do not approach a helicopter unless escorted by flight personnel. Keep all traffic, vehicles, and by-standers 100 feet from helicopter landing zone in all directions. Never walk around the tail rotor area. Discussion Topic: Describe an appropriate landing zone for a helicopter. Describe how you would identify the LZ. Knowledge Application: Review the area around your classroom. Choose and mark a helicopter landing zone. Simulate relaying information about the LZ to an incoming helicopter.

Hazardous Materials Mass Casualty Incidents Incident Management
Advance Preparation Research related multimedia links for illustration purposes. Reach out to local hazardous materials response teams to assist with instruction. Prepare examples of MSDS sheets, chemical labels, and other hazardous material information. Reach out to local/state emergency management agencies for resources relating to multiple-casualty incident management. Review the National Incident Management System and any applicable local incident management plans.

Hazardous Materials Teaching Time: 30 minutes
Teaching Tips: Invite a hazardous materials technician to class. Have him discuss his role and the role of his specialized team. Discuss how his team might interact with other responding EMTs. Demonstrate that not all hazardous materials are found in tanker trucks. Visit the janitor’s closet and review material safety data sheets. Review any placards or warning devices in your area. Hand out copies of the DOT Emergency Response Guidebook. Discuss the placard system. Describe or use multimedia graphics to demonstrate a hazardous materials incident. Discuss the hot, warm, and cold zones. Use real-life examples, if possible.

Hazardous Materials “Any substance or material in a form which poses an unreasonable risk to health, safety, and property when transported in commerce.”—U.S. Department of Transportation (DOT) Point to Emphasize: The Department of Transportation classifies as a hazardous material any substance or material in a form that poses an unreasonable risk to health, safety, and property when transported in commerce. Discussion Topic: Discuss what hazardous materials you might find in your immediate area. What resources might you need to respond to an incident involving these hazards? Class Activities: Tour your building. Identify potential hazardous materials. Review Material Safety Data Sheets. Complete a hazardous materials scavenger hunt. Have students take pictures of hazardous materials that can be found in their response area. Discuss the resources that would be required to respond to an emergency.

Levels of Training First Responder Awareness
(no minimum) First Responder Operations (8 hours) Hazardous Materials Technician (24 hours) Hazardous Materials Specialist (24 additional hours) Point to Emphasize: OSHA and the EPA mandate employers to determine, provide, and document the appropriate level of training for each employee who is expected to participate in emergency response to accidents involving hazardous substances. Talking Points: First responder awareness personnel are trained only to recognize the problem and initiate a response from the proper organizations. First responder operations personnel are trained, as initial responders, to stay a safe distance away, keep the incident from spreading, and protect others from any exposure. Hazardous materials technicians are trained to function to stop the release of the hazardous material by whatever means. Hazardous materials specialists are higher-trained technicians who will also function in command and support roles at an incident. Discussion Topic: Describe the different levels of hazardous materials response training. What level is mandated for EMTs in your area/service?

Responsibilities of the EMT
Recognize hazmat incident Control scene Establish danger zone and safe zone Attempt to identify substance Point to Emphasize: Identification, controlling the scene, and requesting appropriate resources are essential responsibilities of an EMT who is responding to a hazardous materials incident. EMTs first must stay safe also. Talking Points: When you arrive at a potential incident, as an EMT you must restrain your natural impulse to take action. Never assume the scene is safe. When there are multiple medical patients, think hazmat. Establish a danger zone and safe zone and control bystanders out of the danger zone.

Identify Hazardous Material
Signs, labels, placards Binoculars from safe distance NFPA 704 system placards Diamond-shaped DOT labels Other sources MSDS, bill of lading, invoice, manifest Interview workers Talking Points: When safe to do so, identify the substance either from a distance with binoculars, from placards, bills of lading, or Material Safety Data sheets. Discussion Topic: Describe the tools that you might use to identify a hazardous material. Discuss the DOT placard system and the NFPA 704 system. What other resources might help identify a potential hazard? Knowledge Applications: Display pictures of DOT hazardous materials placards. Have groups of students use the DOT Emergency Response Guidebook to identify each hazard and to create a response plan. Discuss. Describe a NFPA 704 warning placard and create a response scenario. Have students discuss response strategies.

Identify Hazardous Material
Get expert advice about next actions Dispatcher Hazardous materials expert Emergency Response Guidebook CHEMTREC ( ) CHEM-TEL ( )

Control Zones Hot zone Warm zone Cold zone
Area of contamination or danger Warm zone Area immediately adjacent to hot zone Cold zone Area immediately adjacent to warm zone Where equipment and emergency rescuers are staged Talking Points: When you are able, establish a warm zone immediately adjacent to the hot zone, which is where patients will be decontaminated, and establish a cold zone for emergency rescuers and non-contaminated equipment to be staged. All EMS personnel and equipment must be staged in the cold zone. Discussion Topic: Describe the hot, warm, and cold zones of a hazardous materials incident. Knowledge Application: Use photographs of a hazardous materials incident (or use a tabletop simulation). Have students identify the hot, warm, and cold zones.

Treatment Area Rehabilitation operations Located in cold zone
Protected from weather Large enough to accommodate multiple rescue crews Easily accessible to EMS units Talking Points: Rescue technicians entering the hot zone are carefully monitored prior to, during, and after emergency operations.

Treatment Area Care of injured and contaminated patients
Decontaminate in warm zone Treat in cold zone Phases of decontamination Gross decontamination Secondary decontamination Point to Emphasize: Decontamination is a process that reduces or prevents the spread of contamination from persons or equipment. EMTs often play a role in this procedure. Talking Points: Decontamination is performed to protect citizens, personnel, equipment and the environment from the harmful effects of the contaminants. The field decon process is designed to remove contaminants and deliver a relatively “clean” patient to EMS personnel for care and transportation. Personal protective equipment should still be worn when treating once contaminated individuals. Gross decontamination is the removal or chemical alteration of the majority of the contaminant. Secondary decontamination is the alteration or removal of most of the residual product contaminant.

Treatment Area Mechanisms for decontamination Emulsification
Chemical reaction Disinfection Dilution Absorption or adsorption Removal Disposal Talking Points: Emulsification utilizes an agent to suspend ordinarily immiscible/insoluble materials such as soap or detergent. Chemical reaction is a process that neutralizes, degrades, or otherwise chemically alters the contaminant. Disinfection removes biological contamination hazards as the disinfectant destroys microorganisms and their toxins. Dilution reduces the concentration of the contaminant. Absorption and adsorption is the process of a liquid or gas penetrating into another substance, such as a liquid into a sponge. Removal is the physical process of removing contaminants by pressure or vacuum. Disposal is the aseptic removal of a contaminated object from a host, after which the object is disposed of.

Treatment Area Decontamination procedures Victims wearing PPE
Victims not wearing PPE Talking Points: Wearing PPE. Rinse, scrub from head down to toes, rinse again, remove PPE, and contain the runoff of hazardous wastewater. Not wearing PPE. Instruct patients via loudspeaker to remove their clothing. Some type of cover should be given for modesty. They should then receive 2–5 minutes of rinse down. Discussion Topic: Describe the general process of decontamination. What steps must the EMT take to complete this procedure? Knowledge Application: Work with a local hazardous materials response team and simulate a decontamination. Discuss the decontamination process and provider rehabilitation. Critical Thinking: How might you identify a hazardous materials incident without placards or warning signs? What might be some warning signs that indicate that a hazardous material might be involved?

Multiple-Casualty Incidents
Teaching Time: 50 minutes Teaching Tips: Use real-life examples of MCIs. Discuss small incidents, such as motor vehicle collisions (MVCs), and compare them to large-scale incidents. Discuss a local disaster plan and describe how certain situations might overwhelm the creation of an MCI plan. Invite a local emergency manager or service chief to class to discuss the regional emergency management/disaster plan. Discuss the National Incident Management System, using examples of large-scale incidents. Explain how each component relates to preparation or response. Practice triage situations in class (even after the completion of this lesson). Make this level of decision making second nature.

Incident Command System
Operations Planning Logistics Finance National Incident Management System (NIMS) Point to Emphasize: The National Incident Management System (NIMS) is centered on the concepts of preparing for, responding to, and recovering from a major incident. Incident command provides a clear management framework for all types of large-scale incidents. Talking Points: NIMS is utilized by federal, state and local governments to manage emergencies in the United States. Command is the person who assumes responsibility for incident management. Single incident command occurs when a single agency controls all resources and operations. In Unified command, several agencies work independently but cooperatively rather than one agency exercising control over the others. Command is assumed by the most senior person of the first service on the scene. Discussion Topic: Describe how your department uses the NIMS system. Which component would best relate to your role as an EMT? Class Activity: Discuss a local disaster plan. Ask the class to preplan an event, using resources laid out in this plan.

EMS Branch Functions Staging area Triage area Treatment area
Transportation area Rehabilitation area Talking Points: In a large-scale incident, command may have delegates to handle other operational functions but in a smaller incident the incident commander should be able to manage all tasks. Knowledge Application: Use programmed patients to create small-scale MCIs. (Consider 4–5 patient incidents.) Train students to think in the framework of an MCI, even in smaller situations.

Triage Goal: afford greatest number of people greatest chance of survival Prioritizing patients Priority 1: Immediate, RED Treatable life-threatening illness or injury Priority 2: Delayed, YELLOW Serious but not life-threatening illness or injury Priority 3: Minor, GREEN Walking wounded Priority 4 ( Priority 0): Non-Salvageable, BLACK Dead or fatally injured Point to Emphasize: Triage provides for the assessment of all the patients and assigns each a priority for receiving emergency care or transportation. Talking Points: Triage is from the French word meaning “to sort.” To accomplish the goal, you must administer care to seriously ill and injured. The easiest first step is to use a loudspeaker to direct all patients capable of walking to move to a particular area. You should rapidly assess the remaining patients, stopping only to secure an airway or stop profuse bleeding. Priority 3 patients can sometimes be used to help treatment by holding a bandage or calmly talking to another patient.

START Triage Simple Triage and Rapid Treatment
Foundation of system is speed, simplicity, consistency of application Simple commands to patients Patient evaluation based on RPM Respiration Perfusion Mental status Talking Points: START triage is the most commonly used method of prioritizing patients in the United States. It is designed to be accomplished within 30 seconds for each patient.

START Triage Able to walk? Respirations present? Yes: GREEN
No: Check respirations Respirations present? Yes and >30/minute: RED Yes and <30/minute: Check pulse No: Position airway; recheck respirations Still no respirations: BLACK Talking Points: If the patient is not breathing and attempts to open the airway are unsuccessful, tag patient as Priority 0. If the patient is breathing more than 30 times a minute, tag as Priority 1; if less than 30, move to next step (check pulse).

START Triage Check Perfusion (Capillary Refill) Good mental status?
> 2 seconds: RED < 2 seconds: Check Mental Status Good mental status? Altered: RED Alert: YELLOW Talking Points: If the patient is unresponsive, not breathing, and has no pulse, tag as Priority 4 (or 0). If the patient is breathing and has no discernible pulse, tag as Priority 1. If the patient is breathing and has a pulse, move to next step (check mental status). If the patient is alert, tag as Priority 2; if not alert, tag as Priority 1. Once these are triaged, re-triage walking wounded. Just because they could initially walk does not mean some Priority 3 patients do not have serious medical conditions. Many could have an altered mental status, be bleeding, and have significant signs of shock, which could cause them to become higher priority patients.

Transportation and Staging Logistics
Triaged and treated patients next transported using priority system Ambulances stage in designated area to await direction and patients Receiving facilities contacted early to determine capabilities and update on expected patient counts Point to Emphasize: Staging and transportation logistics play an important role in supporting the ongoing organization of a multiple-casualty incident. Talking Points: Patients receiving treatment are under the control of a Treatment Area Supervisor. Ambulances awaiting patients are under the control of a Staging Area Supervisor. Once the patients are ready for transport, a Transport Area Supervisor triages order and which ambulance will transport to which destination facility. This is recorded for determining location of patients following an incident. Class Activity: Critique an actual MCI. Discuss with the class what went wrong and what went right. Critical Thinking: How is incident management disrupted? What actions, in particular, might harm the organization of incident management?

Highway Safety and Vehicle Extrication
Advance Preparation Research related multimedia links for illustration purposes. Reach out to local rescue teams for assistance in teaching this lesson. Prepare a vehicle for simulation and scenarios. Prepare rescue and extrication equipment for scenario purposes. Prepare personal protective equipment for demonstration.

Highway Emergency Operations
Teaching Time: 20 minutes Teaching Tips: Use multimedia graphics to illustrate highway scenes. Show providers potential hazards. Use models/toys to present highway scene vehicle placement. Demonstrate personal protective equipment and warning devices. Discuss procedures for using them properly. Use a vehicle to practice exiting and positioning. Discuss best practices.

Initial Response Limited access highways: only primary or first-due units should proceed directly to scene On-scene units: park single file in same direction to minimize on-scene congestion Points to Emphasize: Highway response is a significant safety hazard for EMTs. EMS response at a highway scene should be limited to only the manpower and vehicles needed to accomplish the mission. Talking Points: First-due units should establish command, utilize apparatus for “upstream blocking,” and leave room for rescue trucks as they arrive. Discussion Topic: Describe the potential scene safety hazards of a highway scene. What threats are present? Class Activity: Create a mock highway response. Have students use cars to replicate emergency vehicles and demonstrate proper positioning and exit procedures.

Position Blocking Apparatus
Create one-and-a-half to two lanes of blockage Position apparatus at angle; front wheels rotated away from incident Point to Emphasize: The first-arriving unit at a highway scene should institute “blocking” to protect the work area. Because of its size and weight, fire apparatus is preferred for this purpose. Talking Points: Apparatus operators should consider scene preservation when parking apparatus and avoid running over debris or crash evidence. Parking at an angle with the front wheels turned allows the blocking vehicle to steer away from the responders should it be struck by another motorist. Discussion Topics: Describe the safety responsibilities of the first units on scene at a highway response. Describe the process of positioning a “blocking” vehicle. What types of units are best suited for this role? Knowledge Application: Use multimedia graphics to demonstrate a highway scene. Ask students to discuss initial safety procedures. Critical Thinking: You are confronted on scene by an angry law enforcement officer, who tells you that your blocking vehicle has created a major traffic issue. He demands that you open the lane to traffic. You are concerned that doing this will create a safety issue for responders. What do you do?

Position Other Apparatus
Leave space immediately next to crash for vehicle extrication units Position ambulances, command vehicles, and other units downstream from crash Allows safer patient loading and rapid departure from scene

Emergency Highway Safety
Exit vehicle into safe zone Be alert for oncoming traffic Place flares or cones to slow traffic and channel away from incident lane Night operation: shut off vehicle’s white response lights and headlights Points to Emphasize: Responders exiting apparatus always should exit into the safe zone and should check for oncoming traffic before leaving the vehicle. For further support, EMTs should use protective clothing and warning devices at highway scenes. Talking Points: During night operations, shut off white response lights and headlights so oncoming traffic is not temporarily blinded. Discussion Topic: Describe the specific safety practices associated with nighttime highway operations. How might these operations be different from the ones used in daytime situations? Knowledge Applications: Have groups of students use a tabletop and models/toys to demonstrate proper highway procedures. Focus on vehicle placement. Using actual warning devices, demonstrate deployment and best practice safety procedures.

Vehicle Extrication Teaching Time: 45 minutes
Teaching Tips: Use multimedia graphics to help demonstrate scene size-up. Have on hand and demonstrate examples of safety and appropriate personal protective equipment for extrication. Invite an extrication technician to class. Have him discuss the process and tools of extrication. Consider arranging an extrication demonstration. Contact a local fire department and arrange a dual training. Always assure a safe environment and appropriate personal protective equipment.

Phases of Extrication Preparing for rescue Sizing up situation
Recognizing and managing hazards Stabilizing vehicle prior to entering Gaining access to patient Point to Emphasize: Vehicle extrication often requires specialized training and resources. EMTs should know their local resources and the procedure for activating those resources. Talking Points: Preparing for rescue is a combination of training, practice, and the right protective gear. Your size-up upon arrival should evaluate the scene for hazards and assess the need for additional resources. Hazards should be managed, if not eliminated, before any attempt to reach injured persons is started. Discussion Topic: Discuss the critical elements of a scene size-up as they apply to vehicle extrication. Class Activity: Use multimedia graphics to present a motor-vehicle collision. Ask the class to perform a scene size-up; discuss priorities of extrication.

Phases of Extrication Providing primary patient assessment and rapid trauma exam Disentangling patient Immobilizing and extricating patient from vehicle Providing assessment, care, and transport Terminating rescue Discussion Topic: Describe the ten phases of the extrication process. Discuss the role of the EMT in each phase. Knowledge Application: Review images of motor-vehicle collisions. Discuss the need for extrication in each and the method that might be most effective.

Protective Gear for EMS Responders
ANSI reflective safety vest Point to Emphasize: Proper personal protective equipment is essential at a vehicle extrication scene. EMTs also should consider patient protection. Talking Points: Federal standards require all emergency responders wear ANSI safety vests during highway operations.

Protective Gear Helmets Eye protection Hand protection Body protection
Discussion Topic: Describe the personal protective gear necessary during vehicle extrication. Class Activity: Select and don appropriate personal protective equipment for vehicle extrication.

Managing Traffic Use flares for traffic control
Talking Points: When utilizing flares, remember to avoid spilled fuel, don’t throw flares at moving vehicles, and position flares at 10-foot intervals. Never use a flare as a traffic wand, as it can spew molten phosphorus, which can cause instant third-degree burns.

Air Bags Air bags designed to inflate on impact, dissipate kinetic energy, minimize trauma to body Creates “smoke” in vehicle—cornstarch and talcum powder (and sometimes sodium hydroxide) Point to Emphasize: Airbags and energy-absorbing bumpers can pose a safety risk to responders and should be approached carefully. Talking Points: Disconnecting the vehicle’s power will cause the airbag system to power off in 2–3 minutes, and an undeployed airbag may still fire during this period. Never stand in front of a “loaded” bumper that has been impacted, as it may spring out and strike you.

Electrical Hazards High voltage lines common
Assume entire area around exposed wire dangerous—conductors may have touched and energized Ordinary protective clothing gives no protection against electrocution Talking Points: A broken utility pole is a dangerous obstruction on an emergency scene. Attempting to access a scene that has wires or a broken pole obstructing it should only be done after a utility representative is on scene and has declared the current dead.

Stabilizing a Vehicle Vehicle on wheels
Turn off engine; step-chock three sides Talking Points: This information is to help you understand the process and should not be considered formal training in stabilizing a vehicle. If the vehicle is lying on its side or on its roof, attempting to right the vehicle can cause increased and severe injury to trapped occupants. Entering the vehicle puts the responder at risk if the vehicle is not adequately stabilized. Discussion Topic: Describe the important safety considerations when dealing with the following situations: broken utility pole with wires down, broken utility pole with wires intact, vehicle fires, unstable vehicles. Knowledge Application: Use a programmed patient and a vehicle to simulate motor-vehicle collision scenarios. Discuss stabilization and simple extrication.

Stabilizing a Vehicle Vehicle on side Vehicle on roof
Stabilize with ropes, cribbing, or stabilizer bars Vehicle on roof Utilize 4x4 wood blocks to build crib box

Gaining Access Simple access Complex access
Check if door or window can be opened Try before you pry Complex access Utilize tools and equipment Break glass in side or rear window as far from passengers as possible Point to Emphasize: Gaining access to patients should begin simply and should become more complicated only when simple measures fail. Talking Points: Nader pins are steel-reinforced pins designed to hold a door shut in the event of a collision, thereby keeping the occupants’ door from flying open. Their incorporation into all car doors has made rescue operations more difficult. Complex access generally requires advanced training in vehicle extrication. Once an entry point is gained, a properly dressed EMT should crawl inside and immediately begin the primary assessment.

Disentanglement Gain access by disposing of doors and roof
Makes vehicle interior accessible Creates large exit-way Provides fresh air and helps cool heated patient Talking Points: In most instances, EMTs will not be directly involved in disentanglement other than acting as the patient’s advocate and being the EMT inside the vehicle. However, it is helpful to understand the plan for complex access that may be used by rescue personnel to free the trapped patient.

Disentanglement Disentangle occupants by displacing front end
Easily accomplished with heavy duty jacks and hacksaws Do not cut steering column or airbag wiring; may cause unexpected firing Class Activity: Attend an extrication demonstration. Use appropriate PPE and train with a local fire department or extrication squad. Knowledge Application: Have students work in small groups. Assign each group a particular vehicle extrication hazard (wires down, for example). Ask each group to plan an appropriate approach and extrication strategy.

EMS Response to Terrorism
Advance Preparation Research related multimedia links for illustration purposes. Reach out to the local emergency manager and/or to law enforcement officials for assistance with this lesson. Prepare terrorism response resources for demonstration. Invite assistant instructors and programmed patients to assist with scenario sessions.

Defining Terrorism Teaching Time: 30 minutes
Teaching Tips: Invite a law enforcement officer to class. Ask the officer to discuss the different types of terrorists. The Internet has powerful resources relating to various types of terrorists. Be careful with the validity of sources, but consider using web resources. Use specific examples to link broad concepts to real life. Many high-profile cases are available for discussion.

Terrorism “The unlawful use of force or violence against persons or property to intimidate or coerce a government, the civilian population or any segments thereof, in furtherance of political or social objectives” Talking Points: The quotations defining terrorism are from the Federal Bureau of Investigation. Class Activity: Ask each student to research a terrorist event. Have them discuss whether the terrorism was domestic or international and which element of CBRNE was utilized.

Domestic Terrorism “Groups or individuals whose terrorist activities are directed at a government or population, without foreign direction” Environmental terrorists Survivalists Militias Racial-hate groups Extreme political or religious groups Knowledge Application: Have each student research an example of domestic terrorism. Discuss the threats that come from within.

International Terrorism
“Groups or individuals whose terrorist activities are foreign-based and/or directed by countries or groups outside the targeted country or whose activities cross national borders.” Growing trend toward loosely organized, international networks of terrorists (for example, Al Qaeda) Discussion Topic: Compare and contrast domestic terrorism and international terrorism. How are they different? Knowledge Application: Have each student research an example of international terrorism. Discuss the international threats. Critical Thinking: How might a domestic terrorist event be linked to international groups? Discuss threats that involve both connections.

Types of Terrorism Incidents
Weapons of mass destruction (CBRNE) Chemical Biological Radiological Nuclear Explosive Criminal activities Point to Emphasize: CBRNE is an acronym used to classify the different types of terrorist incidents. It stands for chemical, biological, radiological/nuclear, and explosive. Talking Points: Weapons of mass destruction (WMD) are technological weapons intended to cause widespread harm and/or fear among a population. Terrorism incidents can also encompass criminal activities. In such acts as arson, environmental crime, and industrial sabotage, criminal and technological incidents overlap. Of course, terrorism can also be committed by conventional or unanticipated means, such as flying an airplane into a building. Discussion Topics: Define CBRNE. Describe the various types of terrorist incidents that make up this acronym. Define weapons of mass destruction. How do they relate to CBRNE? Knowledge Application: Have students work in small groups. Assign each group a specific element of CBRNE. Ask groups to describe and discuss the potential hazards of their category.

Terrorism and EMS Teaching Time: 15 minutes
Teaching Tips: Emphasize that first responders are targets. This is a key point that will help protect EMTs if they ever are exposed to this type of event. Use real-world examples and multimedia graphics to make the threats more than just theoretical. Use scenarios and local landmarks to discuss threats in your area.

First Responders as Targets
First responders often principle targets of terrorist attacks Safety of EMS provider is most important consideration when responding to potential terrorist incident Point to Emphasize: Responders often are the principal targets of a terrorist attack. Safety must be the highest priority. Discussion Topic: Discuss the reasons that a terrorist might target first responders. How might this targeting change your response? Knowledge Application: Have students work in groups. Assign each group a terrorist incident in which responders were targeted. Have the group research the incident and discuss response strategies.

Identify Threat Posed by Event
Incident that is a potential act of terrorism is also a crime scene Recognizing OTTO signs may help protect against secondary attack Occupancy (or location) Type of event Timing of event On-scene warning signs Point to Emphasize: The occupancy (location), type, and timing of an event can help responders rapidly identify a potential terrorist incident. Talking Points: Terrorists have historically utilized secondary devices and/or booby traps to target emergency responders.

Occupancy or Location Symbolic or historic targets
Public buildings or assembly areas Controversial businesses Infrastructure systems Talking Points: Symbolic or historic targets include those that represent some organization or event that is particularly offensive in the minds of an extremist individual or group. Public buildings or assembly areas provide the opportunity for attention-getting mass casualties. Controversial businesses are usually those that have a history of attracting the enmity of extremist groups. Infrastructure systems include those operations that are necessary for the continued functioning of society. Class Activity: Ask students to consider their own area. What local buildings and areas might present a target for terrorism? Knowledge Application: Use multimedia graphics to present local buildings. Ask the students to determine terrorist threat levels. Discuss why these buildings might be targeted.

Type of Event Types of events with high suspicion of terrorist involvement Explosions and/or use of incendiaries Incidents involving firearms Nontrauma mass casualty incidents Talking Points: Explosions and/or incendiaries are among the favorite types of weapons used by terrorists. Incidents involving firearms are to be treated as suspicious, especially if they occur in conjunction with other indicating factors. Nontrauma mass casualty incidents have occurred more frequently as the arsenal of terrorism has increased. Any large number of victims without obvious physical injury but with the same or similar symptomology should be considered for terrorist involvement. Critical Thinking: Racial profiling is a serious issue that relates to terrorism. Consider bombings on American soil. What role have Americans played in domestic terrorism?

Timing of Event National holidays
Anniversary dates of previous attacks Incidents occurring in major public areas at busy points of business day Class Activity: Ask students to research and list specific dates that they feel could pose a terrorist threat. Have them describe why they feel that their dates are a threat.

On-Scene Warning Signs
Unexplained patterns of illness or death Unexplained signs and symptoms or skin, eye, or airway irritation Containers that appear out of place Talking Points: When you arrive on the scene, watch for signs of a suspicious incident. Unexplained patterns of illness or deaths can be attributed to chemical, radiological, or biological agents. Some of these substances have recognizable odors and/or tastes. Unexplained signs and symptoms of skin, eye, or airway irritation may be linked to chemical contamination, as may unexplained vapor clouds, mists, and plumes. Remain on the lookout for chemical containers, spray devices, or lab equipment in unusual locations. Watch for items or containers that appear out of place at unusual incidents, which might contain a secondary device. Large fires, spot fires, and fires of unusual behavior may also arouse suspicion, as can anything that appears abnormal for a given incident scene. Discussion Topic: Describe the OTTO signs as they apply to identifying a terrorist incident.

Recognize Harms Posed by Threat—TRACEM-P
Thermal: caused by either extreme heat or extreme cold Radiological: from alpha particles, beta particles, or gamma rays, generally produced by nuclear events Asphyxiation: caused by lack of oxygen in atmosphere Point to Emphasize: The acronym TRACEM-P represents common harms resulting from terrorist incidents. It stands for thermal, radiological, asphyxiation, chemical, etiological, mechanical, and psychological. Talking Points: Thermal harm refers to harm caused by either extreme heat, such as that generated by burning liquids or metals, or extreme cold from cryogenic materials such as liquid oxygen. Radiant heat can melt protective clothing and other equipment. Radiological harm refers to danger from alpha particles, beta particles, or gamma rays, generally produced by sources such as nuclear fuels, by-products of nuclear power production, or nuclear bombs. Asphyxiation is caused by a lack of oxygen in the atmosphere. One common cause of this is heavier-than-air gases such as argon, carbon dioxide, or chemical vapors in a confined space. Extremely dusty situations such as the site of the World Trade Center towers collapse create additional problems.

Recognize Harms Posed by Threat—TRACEM-P
Chemical: caused by toxic or corrosive materials Etiological: caused by disease Mechanical: caused by physical trauma (gunshot, bomb fragments) Psychological: results from any violent event Talking Points: Chemical harm is posed by toxic or corrosive materials. These can include acids (sulfuric), caustics (lye), and chemical toxins (from cyanides to nerve agents). Etiological harm comes from either disease-causing organisms such as bacteria and viruses or toxins derived from living organisms. Mechanical harm is any sort of physical trauma such as gunshot wounds, slip-trip-and-fall injuries, and injury from bomb fragments or shrapnel. Psychological harm can result from any violent or traumatic event. Terrorist events are designed to create fear, invoke panic, reduce faith in government, and cause terror. In fact, this is generally the purpose of a terrorist attack. Responders and victims will be subject to post-traumatic stress and survival guilt. Discussion Topic: Define TRACEM-P. Describe the various harms that make up this acronym.

Time/Distance/Shielding
Teaching Time: 30 minutes Teaching Tips: Refer to lessons on scene safety. These core principles apply to all types of dangerous incidents, not just terrorism. Use multimedia graphics to illustrate and define distance and shielding. Use specific examples of threats posed to responders through length of exposure. Consider radiological and biological events.

Time Minimize time in dangerous area or exposed to hazardous material, biological agent, or radiation Execute rapid entries to perform reconnaissance or rescue Point to Emphasize: Time, distance, and shielding are key considerations in self-protection at a terrorist incident. Responders should use all three forms whenever possible. Just because you feel properly shielded does not mean that you can spend excessive time in close proximity to a contaminated site. Talking Points: Spend the shortest amount of time possible in the dangerous area or exposed to a hazardous material, a biological agent, or radiation. Minimizing your time in the danger zone also reduces the chance of contaminating the crime scene. Discussion Topic: Discuss why first responders should limit scene time/exposure at a radiological incident.

Distance Maximize distance from hazard area or projected hazard area
Follow recommended guidelines regarding hazardous materials in Emergency Response Guidebook Point to Emphasize: Resources such as the Emergency Response Guidebook and the Vehicle Bomb Explosion Hazard and Evacuation Distance Tables can assist EMTs in defining the safe distance associated with particular types of terrorist threats. Talking Points: One example of utilizing distance would be avoiding contact by following the recommended guidelines regarding hazardous material in the current edition of the Emergency Response Guidebook. Discussion Topic: Describe how a responder might know the appropriate evacuation distance for a specific terrorist threat. What resources are available? Knowledge Application: Have students work in small groups. Assign each group a resource and a threat. Ask the group to research and discuss the safe evacuation distance for responders. Critical Thinking: You respond to an incident that you recognize as terrorism. You know that evacuation is necessary, but you do not have specific guidebooks with you. What other resources for evacuation planning might you have?

Shielding Use appropriate shielding for specific hazards
Can be vehicles, buildings, fire-protection clothing, hazmat suits, positive-pressure self-contained breathing apparatus, PPE Vaccinations against specific diseases Point to Emphasize: The term shielding refers both to physical protective structures and to preparations such as vaccinations. Discussion Topic: Describe how shielding might apply to vaccinations. Class Activity: Conduct a tabletop incident. Ask class members to discuss the elements of time, distance, and shielding with regard to incident response. Knowledge Applications: Have students work in small groups. Assign each group a potential harm resulting from a terrorist incident. Ask the groups to discuss how time/distance/shielding might apply to responder safety. Discuss vaccinations required for the EMT class. Ask students to discuss how these might be considered shielding in a terrorist incident.

Responses to Terrorism
Teaching Time: 30 minutes Teaching Tips: Invite a member of the local hazardous materials response team to class to discuss specific threats. Use specific examples to illustrate threats. Use the resources discussed earlier to research response tactics. Biological attacks can be compared to lessons on disease transmission. Compare and contrast these weapons with organic illnesses.

Chemical Incident Includes many classes of hazardous materials
Can be inhaled, ingested, absorbed, injected Can include industrial chemical or warfare-type agents

Harms of Chemical Incident
Thermal (secondary): reactions create heat Asphyxiation (secondary): reactions deplete oxygen Chemical (primary): systemic effects Mechanical (secondary): corrosive chemicals weaken structures Psychological (secondary) Talking Points: Ask for a weather report from dispatch, as it can mean life or death responding through a certain area. Stay upwind and uphill from incident.

Self-Protection Measures
Respiratory protection Protective clothing Be aware of possible contamination from patients Point to Emphasize: Because of the wide variety of hazards posed by chemical agents, responders should take care to use the principles of time, distance, and shielding to minimize exposure risks under all circumstances.

Biological Incident Presents as focused emergency or public health emergency Focused emergency: potential or actual point of origin located; attempts made to prevent or minimize damage and spread Public health emergency: sudden demand upon public health infrastructure with no apparent explanation Point to Emphasize: Biological incidents will present as either a focused emergency or a public health emergency. Talking Points: Responders should be sure to utilize personal protective clothing and respiratory protection. Adequate personal protection equipment should protect the respiratory system, skin, face, hands, feet, head, and body. Protection priorities for the primary responder should be self-protection, using the buddy system, availability of rapid intervention teams, and civilian protection.

Biological Incident Causative agents Bacteria Viruses Toxins
Talking Points: Bacteria are single-celled organisms that can grow in a variety of environments. They cause diseases such as Q fever and typhus. Anthrax, a bacterium, has been the weapon of choice in several American bioterrorist events. Viruses only grow inside of living cells and cause those cells to produce additional viruses. Toxins are poisons produced by living organisms. Often, toxins are distilled from plant material. The extremely potent toxin ricin is distilled from the castor bean plant; a tiny drop of ricin can be deadly.

Biological Incident Four major routes of entry to body
Absorption: skin contact Ingestion: by mouth Injection: from needles or projectiles Inhalation: by breathing Talking Points: Items that affect skin absorption are injury to the skin, skin temperature/blood flow, higher concentration = greater exposure, area with more hair = more exposure, length of exposure, type of agent. Ingestion is a common route to infection. It includes swallowing biological agents in food or drink or accidentally swallowing the agent by itself. One highly likely way to become infected is to eat or drink before completing decontamination procedures. Injection or puncturing can be accidental or purposeful. Personnel can become infected by accidentally injecting themselves through improper handling of a needle or puncturing themselves with a jagged piece of debris. Inhalation has the potential to cause more biological agent infection than any other route of exposure, provided the particle is small enough to reach the lower respiratory tract. Knowledge Application: Have students work in small groups. Assign each group a specific route of entry for a biological agent. Have groups research and provide examples. Use specific incidents when applicable.

Exposure/Contamination
Exposure: substance taken into body through route of exposure Contamination: substance clings to surface areas of body or clothing Talking Points: Biological agents can usually be washed out of clothing. In most cases, clothing and PPE can be reused after decontamination. Removal of clothing removes most of the contamination. It is important to ensure that a patient’s dignity is protected during the decontamination operation. Many services carry extra Tyvek suits or a box of oversized trash bags to cover patients whose clothing has been removed. Discussion Topics: Describe a biological agent’s four major routes of entry into the body. Define exposure. How is it different from contamination?

Harms of Biological Incident
Chemical (secondary): scene of clandestine laboratory Etiological (primary): agents classified as poisons Mechanical (secondary): explosives used to disperse agents Psychological (secondary)

PPE and respiratory protection Get as much information as possible Prioritize protective measures Self-protection Buddy system Availability of rapid intervention teams Civilian protection

Radiological/Nuclear Incident
Small nuclear devices (“suitcase bombs”) stockpiled in foreign nations Radiologic dispersion more practical and difficult to detect as radiation symptoms are delayed for hours or days Sickness treatable if detected early Point to Emphasize: Identifying a nuclear incident may be difficult because radiation cannot be detected by the senses and because symptoms of radiological exposure generally are delayed for hours or days. Critical Thinking: Identification of a terrorist incident may not always be initially possible. What protective measures should you take if you already are inside a scene when you realize that it may be a terrorist incident?

Harms of Radiological/Nuclear Incident
Thermal (primary): nuclear explosion Radiological (primary): radiological materials (ongoing hazard) Chemical (secondary): radiological substances also chemical hazards Mechanical (primary): explosion Psychological (secondary)

Time, distance, shielding Radiologic detecting equipment helps determine effectiveness of measures Assume dissemination of radiological, biological, or chemical materials Follow decontamination procedures

Explosive Incident Wide variety of devices from small pipe bombs to large vehicle bombs May involve attacks on a fixed target or group of people May be designed to disperse biological, chemical, or radiological materials Talking Points: Bombs and explosives have been and probably will continue to be the most frequently used weapons by terrorists. Explosives can be separated into two categories: high-order produces defining supersonic overpressurization shock wave; low-order creates subsonic explosion and lacks overpressurization wave.

Harms of Explosive Incident
Thermal (primary): heat of detonation Asphyxiation (secondary): possibility of extremely dusty conditions Chemical (secondary): result of explosive reaction from chemicals present at detonation site Mechanical (primary): typically seen at bombing incidents Psychological (secondary) Talking Points: Responders need to be concerned both preblast and postblast. Preblast is that portion of operations occurring after a written or verbal warning. Postblast are the operations occurring after at least one detonation has occurred.

Responder needs both preblast and postblast protection Preblast: operations occurring after written or verbal warning received but before explosion takes place Postblast: operations occurring after at least one detonation Discussion Topic: Describe the specific self-protection measures associated with the following types of incidents: chemical, biological, radiological, explosive. Class Activity: Provide specific examples of terrorist attacks. Ask the class to classify the type of attack; discuss specific harms and protective measures used. Knowledge Application: Have students work in small groups. Assign each group a specific type of terrorist threat. Have the group research and discuss specific harms and protective measures for responders.

Dissemination and Weaponization
Teaching Time: 15 minutes Teaching Tips: Relate this lesson to previous lessons on the respiratory system. Discuss dissemination in the context of the cardiopulmonary system. Ingestion and absorption relate to anatomy and physiology lectures. Discuss these routes in the context of the GI system and the anatomy of the skin. Use real-life examples of weaponization. Discuss the anthrax attacks of the early 1990s.

Dissemination of CBRNE Materials
Respiratory route Most effective, most common means Ingestion route Dermal route Human-to-human contact Talking Points: The most effective and most common means of dissemination is to enable the material to enter through the respiratory tract. Effectiveness of the ingestion, or alimentary, route of exposure depends on whether the agent can survive the stomach’s acidic environment. (An example is anthrax, a bacterium that can survive for long periods of time and in harsh environments as dormant spores.) The dermal route of exposure (through the skin) is very effective with blister agents (vesicants), but less effective with many biological agents. Nerve agents such as sarin, soman, or taban easily penetrate the skin and cause systemic effects. Some bacterial and many viral agents can be disseminated effectively by human-to-human contact. With such agents, especially when there is a delayed incubation period, it is possible to infect a large population prior to detection. These factors are of particular concern with smallpox, pneumonic plague, and viral hemorrhagic fevers. Discussion Topics: Define dissemination. Discuss the major methods used to disseminate an agent. Explain why the respiratory route is an effective means of dissemination. Class Activity: Discuss how dissemination relates to issues such as the spread of everyday infections. How is the movement of a biological agent similar to the spread of the flu?

Weaponization of CBRNE Materials
Most effective when targeted through inhalation route Particles in 3–5 micron size Such airborne dissemination can be created by applying energy to material Heat, explosives, sprayers can aerosolize materials Point to Emphasize: Weaponization is the application of technology to improve dissemination performance to achieve maximum distribution. Discussion Topic: Define weaponization. Describe how this term relates to the dissemination process of an agent. Knowledge Application: Have students work in small groups. Assign each group a specific biological agent and ask the group to research and discuss how the agent is disseminated. Discuss specific examples when possible. Critical Thinking: What might be on-scene clues that an agent has been disseminated? What types of devices might be used in a dissemination process?

Characteristics of CBRNE Agents
Teaching Time: 45 minutes Teaching Tips: Use specific examples when discussing characteristics. Compare these examples to everyday substances. For example, discuss the volatility evaporation of alcohol when discussing chemical weapons. Invite a law enforcement officer to discuss capsicum (pepper) spray. This is a commonly used riot control agent. There are graphic multimedia examples of SLUDGEM. Use video graphics to describe assessment findings. Refer to the lessons of Chapter 28 and discuss injuries associated with blasts or explosions.

Chemical Agents Can be gaseous, liquid, or solid
Vapor pressures and densities can vary across the spectrum Volatility Low boiling point and high vapor pressure will evaporate more readily Allows agent to have greater airborne release potential Talking Points: Some emergency and rescue services carry detectors to help identify the presence of various CBRNE agents. The picture shows a chemical agent monitor.

Classes of Chemical Agents
Choking agents Predominately respiratory Vesicating (blister) agents Cause chemical changes in cells of exposed tissue Cyanides Prevent use of oxygen within cells Point to Emphasize: Choking agents, vesicating agents, cyanides, nerve agents, and riot control agents are common classifications of chemical weapons.

Classes of Chemical Agents
Nerve agents Inhibit enzyme critical to proper nerve transmission, causing out-of-control parasympathetic nervous system Riot control agents Irritating materials and lacrimators (tear-flow increasers) Discussion Topic: Describe the different classifications of chemical weapons. Describe their effects on the body.

Nerve Agents—SLUDGEM Signs and symptoms of exposure Salivation
Lacrimation Urination Defecation GI Upset Emesis Miosis Point to Emphasize: SLUDGEM is a mnemonic that is used to remember the signs and symptoms of nerve agent poisoning. The letters stand for salivation, lacrimation, urination, defecation, GI upset, emesis, and miosis. Talking Points: Nerve agents typically inhibit acetylcholinesterase, causing overstimulation of the parasympathetic nervous system. The signs and symptoms of exposure to nerve agents can be remembered by SLUDGEM. Discussion Topic: Define the mnemonic SLUDGEM. Describe the associated signs and symptoms. Knowledge Application: Have students work in small groups. Assign each group a chemical weapon type. Have the group research and present the weapon’s potential harm and responder protective measures.

Biological Agents Role of EMS primarily supportive
Some material can replicate itself creating greater potential for transmission from person to person Points to Emphasize: The primary concern for all biological agents is personal protection if the agent is transmitted from human to human. Infectivity, virulence, toxicity, incubation period, transmissibility, lethality, and stability are factors that influence the potential for a substance to be used as a biological weapon. The picture shows a detector kit for gases, vapors, and aerosols. Discussion Topic: Describe the features that make a substance a potential biological weapon. Why do different biological weapons have different epidemiological impacts? Knowledge Application: Have students work in small groups. Assign each group a specific biological threat (such as anthrax). Have the group research and present specific harms and responder protective measures. Critical Thinking: Weaponization of biological agents often includes combining diseases. What new threat might a combined agent pose?

Radioactive/Nuclear Devices
Military nuclear device Improvised nuclear device Radiological dispersal device (dirty bomb) Sabotage Point to Emphasize: There are four potential scenarios for a nuclear weapon attack: a military nuclear weapon, an improvised nuclear weapon, a “dirty bomb,” and the sabotage of a nuclear facility. Discussion Topic: Describe the potential scenarios for a nuclear event. Knowledge Application: Use a programmed patient to create CBRNE scenarios. Have teams of students practice recognition and treatment strategies.

Effects of Radiation Radiologic exposure affects bone marrow, gastrointestinal system, central nervous system Talking Points: The picture shows a radiation detector.

Incendiary Devices Blast injury patterns
Lung injury: bradycardia, apnea, and hypotension from blast wave Ear injury: rupture of tympanic membrane Abdominal injury: rupture of gas-containing section of intestine Brain injury: concussion or mild traumatic brain injury (MTBI) from blast wave Talking Points: The explosion of an incendiary device typically causes high energy overpressurization, a blast wave, and a low energy blast wind. These cause common injury patterns. Responders treating victims of blast injuries at a terrorist incident should act as they would with patients at any other thermal or blast injury incident. Class Activity: Have the class complete a research paper on a CBRNE topic of their choice. Include potential harms and protective measures.

Strategy and Tactics Teaching Time: 25 minutes
Teaching Tips: Oftentimes tactics and priorities cross the service boundaries of EMS, fire, and law enforcement. Consider using these agencies to participate in this lesson. Safety is still the highest priority. Now implement the principle of force protection. Use real-life examples and multimedia graphics to demonstrate the difficulties of isolation and perimeter control. Review your state’s statutes and guidelines regarding terrorist incident notification. Which agencies would need to be notified?

Isolation Controlling scene, isolating hazards, and attempting to conduct controlled evacuation is resource-intensive and requires law enforcement personnel Law enforcement must establish and control perimeter throughout incident Points to Emphasize: Important priorities for responders at a terrorist incident are life safety, incident stabilization, and protection of property. Responders should consider isolation and perimeter control of a terrorist incident. Establishing control zones early will enhance public protection and will facilitate medical treatment. Talking Points: A strategy is a broad general plan designed to achieve desired outcomes. Tactics are specific operational actions taken to accomplish their assigned tasks. Discussion Topics: Describe the immediate and general priorities of responders to a terrorist incident. Describe the process of isolation at a terrorist incident. How might this process be executed? Describe why perimeter control at a terrorist incident is important. Discuss how to initiate this tactic. Class Activity: Conduct a tabletop exercise. Involve law enforcement and fire officials as you discuss general strategy and tactics. Knowledge Application: Use multimedia graphics or a city map. Describe a terrorist incident; then have groups of students discuss tactical issues such as isolation and perimeter control. Describe real local challenges.

Notification Generally required by established directives, procedures, and statutes Request for additional specialized agencies carried out by communications center based upon early reports of EMTs on scene Point to Emphasize: In a terrorist event, it is critical that appropriate response and support agencies (at local/state/federal levels) be notified. Established directives, procedures, or statutes usually require such notification. Discussion Topic: Discuss the required notifications in the event of a terrorist incident. Which agencies must be notified? Class Activity: Use a local emergency management plan to discuss the process of involving additional agencies in a terrorist incident. Describe how notifications would be made. Critical Thinking: What role might you, as an EMT, play in notifications? Consider your service’s disaster plan and describe the role that you might play.

Identification and Protection
Identification of agent Observe indicators of particular agent or presence of chemical containers or lab materials Protection of critical assets People, vehicles, equipment/supplies Requires close partnership between EMS and security agencies Point to Emphasize: Force protection refers to steps taken to ensure the safety of responders and their equipment. This concept is essential in a terrorist incident. Knowledge Applications: Critique an actual event. Discuss tactics used at a major incident. Discuss force protection at a terrorist incident. Describe an incident and have groups of students list force protection strategies.

Decontamination Gross decontamination by EMS personnel
Removing surface contamination via mechanical means and initial rinsing Amount of surface contamination significantly reduced

Self-Protection at a Terrorist Incident
Teaching Time: 15 minutes Teaching Tips: This section is primarily a review of topics previously covered. As safety is such an important issue, use this opportunity to drive home key points. Use scenarios to evaluate safety comprehension. Add terror-related elements to scenarios in an ongoing fashion, not just under the heading of this chapter.

Recognition: Scene Size-up
Victims displaying signs of hazardous substance exposure? Unconscious victims? Victims exhibiting SLUDGEM signs? Blistering, reddening of skin, discoloration or skin irritation? Victims having difficulty breathing? Point to Emphasize: Scene size-up and situational awareness will help identify potential hazards associated with a terrorist event. Knowledge Application: Discuss a backward scene size-up. Ask the class what information might be important to them if they were the second unit responding to a major incident. Discuss how a proper (or improper) scene size-up might impact them.

Recognition: Situational Awareness
Medical mass casualties or fatalities with minimal or no trauma Responder casualties Dead animals and vegetation Unusual odors, color of smoke, vapor clouds Knowledge Application: Present tabletop scenarios. Ask groups of students to formulate protective strategies for responding to the described incident.

Remember OTTO Clues Occupancy (location) Type of event Timing
On-scene clues Discussion Topic: What key tactics of personal protection are necessary at a terrorist incident?

Don’t Rush In Wait until appropriate authority says scene is safe
Follow incident command protocols Wear appropriate PPE Beware possible secondary explosive devices Search all patients for explosives or weapons Point to Emphasize: Providers should never rush in. They should respond only when it is safe to do so—when proper protective measures have been taken.

Protect Yourself Understand TRACEM-P harms Time, distance, shielding
Use specific tactics for each CBRNE threat Points to Emphasize: Safety is the first priority when responding to a terrorist incident. Specific protective measures apply to the different types of terrorist incidents. Providers should understand the particular threats of CBRNE incidents. Discussion Topic: Describe the key personal protection measures with regard to the following types of incidents: chemical, biological, radiological, explosive. Knowledge Application: Use a programmed patient to create CBRNE scenarios. Discuss individual safety. Critical Thinking: There have been many examples of responders being injured while trying to save the lives of others. Discuss the motivation and thought process behind such events. Why might such acts actually be counterproductive to the rescue effort?

EMS Operations Advance Preparation

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