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Hospital preparedness
has taken on a whole new meaning in the post-9/11 era.
Now, healthcare providers have to be ready to deal with
nuclear, radioactive, biological, explosive or chemical
terrorism. University Hospital is helping to lead the
way in New Jersey.
Life after 9/11 has
never been the same in the United States. Ask anyone
who’s been to an airport or gone to a concert
recently.
The threat of terrorism
has also changed the way hospitals prepare for emergencies.
Generally speaking, before 9/11, hospitals’ plans
were based on natural disasters or emergency scenarios
that could occur in their communities.
Now more than ever, all
hospitals have to be ready for a whole host of Chemical,
Biological, Radiological, Nuclear, or Explosive (CBRNE)
incidents, such as the following:
- The “C”
in CBRNE stands for chemical agents such as sarin,
a substance known as a nerve agent that affects the
nervous system. Sarin can be released into the air
or onto the ground or surfaces to cause its effects.
It is “supertoxic” and fast acting. Most
people with mild or moderate exposure to sarin will
survive, with no long-term consequences to their health.
However, people exposed to large doses of sarin could
lose consciousness, experience convulsions, develop
respiratory failure, and possibly die.
- An example of a biological
agent is Yersinia pestis, a bacterium that, if used
in an aerosol attack, could result in pneumonic plague.
If a group of people were exposed to Y. pestis, which
can cause pneumonia, they could unknowingly spread
the biological agent to others by coughing or sneezing.
In some cases, pneumonia can lead to serious illness
or even death.
- A “dirty bomb”—a
conventional weapon (explosive) that sends radioactive
material into the air upon detonation—is an
example of a radiological agent. According to the
Centers for Disease Control and Prevention, the primary
threat of a dirty bomb is the blast itself. The levels
of radiation in a dirty bomb would probably be low;
however, people exposed or possibly exposed to a dirty
bomb would need to be decontaminated and given a medical
evaluation and treatment, if necessary.
- A nuclear incident
refers to the detonation of an atomic bomb—be
it a warhead, a suitcase bomb, or other device. Such
a blast would produce a whole range of traumatic injuries,
compounded by the effects of toxic levels of radiation
released in the explosion and subsequent fallout.
- An explosive incident
could include the detonation of a conventional bomb,
or, as demonstrated by 9/11, an attack using a vehicle
such as an airliner that carries its own load of highly
explosive fuel. This type of attack would result in
more conventional forms of traumatic injuries.
Before and During
University Hospital has
a history of playing key roles during times of crisis.
The hospital’s Emergency Medical Services (EMS)
Special Operations Group (SOG)—a select team of
highly trained paramedics and emergency medical technicians
(EMTs)—responds 24/7 to disasters and mass casualties
locally and throughout the region. Its members have
helped evacuate nursing home residents; responded to
a chemical factory explosion in Lodi; and were on scene
for four days in Bound Brook during Hurricane Floyd.
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University Hospital
EMS has a fleet of 28 basic life support and 12
advanced life support ambulances and provides care
24-hours-a-day. |
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On 9/11, University Hospital
personnel responded to the unfolding crisis on many
levels. As planned following the first World Trade Center
attack in 1993, University Hospital EMS was in charge
of coordinating New Jersey’s emergency response.
An EMS task force was sent to Ground Zero to assist
with rescue efforts.
However, there was such
an influx of victims from New York City that most University
Hospital and other New Jersey EMS personnel were assigned
to mass casualty centers in Hoboken, Jersey City, and
Liberty State Park. Meanwhile, University Hospital had
its emergency system in operation and was prepared to
receive many patients, but the majority were either
treated at the scene or admitted to New York hospitals.
For nearly two weeks
after the attacks, New Jersey mutual aid responders—including
those from University Hospital EMS—were at the
scene, first as part of a rescue effort, then as a recovery
mission. University Hospital EMS were the “commanders”
of the various EMS task forces that assisted New York
City with mutual aid in the two weeks after the attacks.
Afterward, there were
plenty of lessons learned, including the realization
that the “rules” of emergency preparedness
had suddenly changed. Hospitals needed to be ready for
terrorist activity.
“September 11 was
a wake-up call for hospitals,” says Dr.
William Gluckman, an assistant professor of surgery
at New Jersey Medical School, an emergency department
physician at University Hospital in Newark, and associate
medical director of the hospital’s EMS. “Hospitals
are better prepared today, but there’s still a
long way to go.”
A Partner in
Preparedness
In
its role as the Level I trauma center for northern New
Jersey and the largest provider of EMS services in the
state, University Hospital has been an active partner
with UMDNJ’s Center for BioDefense, a regional
and national leader in bioterrorism science, preparedness,
and response.
The Center for BioDefense
was established in Newark in 1999 as a scientific research
institute. The Center’s researchers set out to
study biological agents that could be used in bioterrorism
attacks; specifically, working to develop detection
strategies, including a blood test that can identify
infectious agents at their earliest stages.
Following September 11,
the Center’s scope broadened beyond the scientific
realm; it is now on the forefront of several bioterrorism
and other Weapons of Mass Destruction (WMD)/Homeland
Security initiatives including public health, training
and education, clinical readiness, and emergency response.
In 2003, the New Jersey Medical School received a nearly
$21 million National Institutes of Health grant to build
a regional biocontainment facility. The facility will
house a Biosafety Level 3 laboratory and serve as a
central location for top infectious disease researchers
throughout the Northeast region to work.
The Center’s emergency
preparedness component is highly regarded for its training
of first responders throughout New Jersey. University
Hospital EMS works with the Center’s Incident
Support and Operational Planning (ISOP) unit to develop
and conduct exercises, drills, and training programs
for law enforcement agencies, fire departments, hazardous
materials teams, EMS units, and public health organizations
throughout the state.
Now, the Center has an
emergency response team of its own that includes several
University Hospital EMS members. “The Center for
BioDefense and University Hospital EMS have a longstanding
relationship,” says Brendan McCluskey, deputy
director of the Center for BioDefense. “It wasn’t
until recently, however, that we had the staff to form
an emergency response team of our own.”
The team includes four
members of the Center for BioDefense and eight members
of University Hospital E
MS. Mr. McCluskey says
the team will respond to bioterrorism-related emergencies
and other types of disasters, helping to set up the
incident command system and working with other agencies
called to the scene. Enhancing the team’s response
capabilities is one of three fully equipped special
operations vehicles purchased by the Center; the other
two units will be based at hospitals in New Brunswick
and Camden as part of New Jersey’s statewide EMS
and domestic preparedness plan.
Ready in Newark
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Decon units were set
up to cleanse workers at Ground Zero. University
Hospital frequently drills and trains staff on how
to set up similar tents outside the Emergency Department
during a crisis. |
For the past two years,
terrorism-related courses for medical and non-patient
care staff at hospitals have received high priority.
At University Hospital, the Center for BioDefense has
trained much of the staff, including physicians, nurses,
and other support staff, in the recognition of incidents
and the initial assessment of patients exposed to WMD
and hazardous materials, as well as in the principles
of incident command.
One WMD-related concern
is the consequences of hazardous materials exposure
at the hospital. University Hospital administration,
along with some specially skilled University Hospital
emergency physicians, worked in conjunction with the
New Jersey State Police Domestic Preparedness Unit to
train and develop a hospital-wide decontamination team
of nurses, physicians, security, and housekeeping personnel
to oversee the proper decontamination procedures.
“If a contaminated
person entered the emergency department, it could potentially
be a very harmful situation,” says Dr. Gluckman.
“University Hospital emergency department personnel
have been trained to identify possible contamination
and know what procedures to follow.”
There are no effective
one-size-fits-all plans when it comes to agents of terrorism.
CBRNE incidents each have their own unique response
procedures. University Hospital has established detailed
procedures for a variety of terrorism scenarios.
Suppose there is an outbreak
of smallpox in the Newark area, and someone presenting
with symptoms of this contagious, airborne disease comes
to the University Hospital emergency room for treatment.
The patient would be taken to a negative pressure room,
where airflow is reversed into the room to prevent the
spread of airborne elements.
In addition to following
universal infection control procedures (handwashing,
the wearing of gloves, gowns, etc.), caregivers would
further protect themselves by taking what’s known
as Droplet procedures. This includes wearing special
masks rated N95, which block 95 percent of particles
0.3 microns in size or larger. A micron is 1/1,000th
of a millimeter. If the smallpox patient needed to be
transported to another facility, he would wear the N95
mask also. The linens used by a smallpox patient would
be bagged and autoclaved (a method that uses pressurized
steam to kill microorganisms), and surfaces in the room
would be wiped down with a bleach solution.
Additionally, says Dr.
Gluckman, anyone exposed to the smallpox patient, such
as other people in the emergency room waiting area,
would need to receive the smallpox vaccination. Anytime
a biological weapon or a highly contagious element is
suspected, the hospital would notify the Centers for
Disease Control and/or the FBI and local law enforcement.
In the event of a nuclear/radiological
attack, patients would be decontaminated outside of
University Hospital’s emergency department in
a special tent. They would be showered with water and
washed with soap; clothing (which can transmit agents
of nuclear/radiological terrorism) would be disposed
of by hazardous materials personnel. Once decontaminated,
the patients would be evaluated and treated first for
non-radiation injuries; then for the radiation exposure.
Decontaminated patients do not pose a danger to hospital
staff or other people.
Hospitals also have to
be ready for the surge in patients during an emergency.
On any given day, a hospital has a certain number of
beds it can expect to fill, and staffing and supplies
are planned for accordingly. But during an emergency,
many more patients come to the hospital, causing a shortage
of beds and a drain on staff and resources.
“University Hospital
is well prepared for surge capacity,” says Mr.
McCluskey. “There are sections in the hospital
that can be converted quickly to accommodate additional
patients. Our proximity to New Jersey Medical School
and other UMDNJ schools in Newark would enable us to
call on medical students and other health personnel
for help.”
New Jersey hospitals
have also established a way to communicate during emergencies
when phone lines and computer systems may be down. Each
of the 85 acute care hospitals has an 800 megahertz
radio communications system that interconnects them
so they can share critical information and resources.
The system also links up with New Jersey’s Office
of Emergency Management and the Department of Health.
And then there’s
the issue of hospital security, which has stepped up
since 9/11. James Howson is the director of emergency
preparedness for the New Jersey Hospital Association
(NJHA), which represents most of the acute care and
specialty hospitals in the state.
“Three years ago,
a person could enter a hospital through almost any of
its doors. Now, many of those doors are locked or accessible
only with a key card,” he says. “In many
cases, cars aren’t allowed as close to the hospital
building as before, and visitors are restricted to certain
areas. These measures aren’t all a reaction to
possible acts of terrorism; they also deter crime and
help protect valuable medical equipment.”
When the Threat
Levels Rise
The Department of Homeland
Security’s color-based advisory system ranges
from low (green) to severe (red) based on the intelligence
information at hand. The NJHA has prepared guidelines
advising hospitals what steps to take at the different
threat levels, but they aren’t made public for
security reasons, says Mr. Howson. “When a threat
advisory changes, many of the actions a hospital takes
are unnoticeable to the average person,” he says.
Mr. McCluskey agrees.
“At University Hospital, personnel with pivotal
roles in our disaster management plan would ensure that
we’re ready, for example, by testing communications
equipment more frequently. Any actions taken are then
communicated to the entire staff, but the public wouldn’t
be aware of anything different,” he says.
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Even though many hospitals,
like University Hospital, can accommodate a surge in
patients during a time of crisis, it’s important
that the public be prepared to handle small matters
themselves. That often involves planning ahead. Ambulances
should be called only for a true emergency. Also, it’s
important to pay attention to directions and announcements
made on TV or the radio. For example, by tuning in,
a patient could learn that a hospital has cancelled
elective surgeries for the day.
Most hospitals have websites,
and they should be checked for updates on how they are
responding to an emergency situation. For example, University
Hospital’s website— www.TheUniversityHospital.com—has
a special system to display important information and
instructions to the public during a crisis situation,
such as how to determine if a loved one has been admitted
or if normal operations have been suspended.
During an emergency,
the public should stay home unless directed to leave
by authorities. Everyone should try to remain calm,
especially those at the incident scene. “People
at an incident scene need to listen to instructions
given by EMS, the police, or the fire department, as
well as hospital personnel. If decontamination procedures
are required, there will be a slight delay in being
treated in the emergency department,” says Dr.
Gluckman. “The measures taken by a hospital during
an incident are designed to preserve everyone’s
safety and well being.”
For
more information about University Hospital EMS, visit
their website at: http://www.uh-ems.org.
To learn about the Center for BioDefense, visit: http://biodefense.umdnj.edu/
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