Metropolitan medical strike team - MMST - is a new term in the fire service. The role of the MMST is to provide decontamination and medical treatment for up to 1,000 victims in the event of a terrorist attack. It is not, however, as simple as it sounds.
Photo by Christopher A. Palmisano Emergency medical personnel enter the hot zone with stretchers to recover non-ambulatory victims during a recent full-scale terrorist drill in Philadelphia that was designed to test domestic preparedness.
The MMST is an outgrowth of the U.S. Department of Justice's new domestic preparedness initiative. The department's Office of Justice Programs is providing terrorism-response training and equipment to fire departments throughout the country (see "Janet Reno Speaks Out," October 1998). Philadelphia is one of 27 cities designated to form a metropolitan medical strike team. The Philadelphia Fire Department's accomplishments in creating its MMST can serve as a guide to other agencies.
Step 1: Education
The first step in building a team is education. To build an effective MMST, chief officers and other members must be aware of the properties of the agents used by terrorists and how to mitigate such incidents with the vast amounts of tools and equipment available. Once you have a good knowledge of the NBC (nuclear, biological and chemical) threat, you can plan to fight it.
Step 2: Planning Committee
The next step is to select a planning committee. Choose individuals from your fire department and outside support agencies who are experts in their fields and trained in terrorism to at least the awareness level. Suggestions include personnel from your hazardous materials task force, communications division, EMS division, fleet or vehicle management, safety department, fire training division, local and federal law enforcement, local military support units, local hospital administrators and local office of emergency management, as well as others as you see fit.
The final additions and most important part of your planning committee will be procurement experts, training personnel and an equipment research team. The reason for this is simple: your ability to respond to acts of terrorism is only as good as the equipment and training used to fight it. You need people on your team who can find equipment that is not only appropriate for handling the NBC agents, but also must be compatible with the equipment you currently use.
Step 3: Equipment Selection
As the equipment procurement officer for the Philadelphia Fire Depart-ment's Hazardous Materials Admini-strative Unit, I found myself researching equipment that I haven't seen since my military training at Redstone Arsenal Chemical School. I started a comprehensive research program via the Internet, but also by consulting vendor catalogs and making numerous phone calls to manufacturers.
Look for products that are easy to use, and ask vendors to set up demonstrations and train-the-trainer programs. The bulk of the MMST team will be made up of firefighters who have never responded to a hazmat incident. Training and pre-plans have proven to be the backbone of the successful response to emergencies. The MMST response is no exception.
Photo by Christopher A. Palmisano Local Army National Guard troops assist with chemical agent monitors during the Philadelphia exercise. They are checking personnel for contamination as they exit the warm zone.
The proliferation of terrorist-response programs throughout the country has caused delays in the distribution of equipment from vendors. Many fire departments across the country are buying terrorism-response equipment. Because of heavy demand, many items for personal protection and decontamination are on back order. When you contact a vendor, ask about availability and delivery dates.
Decontamination needs include tents, decon trailers or inflatable shelters with heated water and solution mixers; portable decon showers; containment pools with elevation grids; pumps for off-loading contaminated liquids from pools; recovery drums (55 gallons); overpack drums (95 gallons); lighting; hoseline manifolds for water supply with garden-hose spigots; garden hoses; five-gallon poly buckets; long-handle brushes; bleach; plastic tarpaulins for setting up collection areas in the hot zone; bags for victims' personal belongings; large plastic trash bags for contaminated items; duct tape; barrier tape; disposable towels to dry victims; and re-dress for victims such as lightweight Tyvek suits or disposable blankets. Depending on your current equipment on hand, the list can go on.
The medical response of the MMST requires pharmacology and emergency medical equipment like atropine, intravenous solutions, splints, stretchers and, unfortunately, body bags. This is where medical-support experts come into play.
Personal protective equipment (PPE) needs include decon suits; respiratory and eye protection; knee-high boots; gloves; helmets or hard hats; ID vests; and dosimeters for nuclear attacks.
Any of the PPE placed in service for the MMST must protect members from terrorist agents. Having a variety of PPE choices lets the MMST operate safely in different types of attack environments. Choose PPE for the different roles of each member of the MMST; for example, medic drivers may be better off wearing powered air-purifying respirators (PAPRs) rather than self-contained breathing apparatus (SCBA).
The more new equipment being introduced to the MMST, the more training members will need. As the list of equipment grows, so does the responsibility of owning it. Keep it simple, yet effective.
Photo by Christopher A. Palmisano Hazmat technicians receive medical evaluation and a break after conducting hot zone entry team operations that were part of the Philadelphia exercise.
Another factor in equipment procurement is "green purchasing" - buying items that are environmentally friendly. What good is it to spend large amounts of money on the protection of our citizens from the possibility of a terrorist attack if we are inadvertently polluting the planet and stripping it of its natural resources? Ask vendors about the shelf lives and disposal methods for expiring items.
Step 4: Vehicle Selection
Now you must determine how to get the team and equipment to the scene of an emergency. There are a few choices: a box truck, straight truck with lift gate or trailer-type vehicle. Which-ever type of transport vehicle you choose, a ramp or lift gate for off-loading the equipment is recommended.
Step 5: Training Program
Each member of the MMST must be trained in the strategies and techniques of mass decontamination. The lessons will range from how to tow a decon trailer and setting up zones to triage, PPE and the transport of victims.
Have your fire training division, emergency medical department and hazmat division work together and develop a comprehensive training course. Give the students plenty of hands-on experience with the equipment and hold exercises at least once a year. This will help keep the team sharp and test the equipment. Train backup personnel for emergencies.
Firefighters instinctively want to do a good job. Keep their morale up by introducing them to the MMST role with a good training program. Thrusting the MMST members through an inept training program can create resentment.
Step 6: MMST Operations
Let's put the MMST in service at the scene of a mass-casualty attack and see what kind of problems an incident commander may face.
First, anticipate an attack. If your city is involved in major public events, place the MMST on standby or at least make the team aware of activities and locations of such events. Terrorists get their point across by causing mayhem in places where there are large crowds.
If an attack occurs and the MMST is called out, personnel will be at a premium. Take, for instance, a fire station containing an engine and ladder company with a mass-decontamination trailer fully equipped for MMST response (six or seven firefighters and two officers). Watch how quickly your personnel resources are depleted:
- Ladder officer - Supervises decon operations and the setting up of equipment, tents, showers, lighting, etc.
- Engine officer - Handles communications, transport of victims, water supply and donning of PPE.
- Engine driver - Supplies water.
- Ladder driver - Supplies electric power for fans, pumps, lighting and decon equipment.
- One firefighter - Assists the decon team in donning PPE.
- Four firefighters - Once in PPE, they off-load the trailer or decon vehicle, set up the tents and showers, and begin decon operations.
That's everyone. If the team is wearing 30-minute SCBA, your decon station is out of operation in about 20 minutes. After a decon station operates for about 15 minutes it's time to start off-loading the containment pools, again taxing your resources. Decon team members potentially are contaminated; before being relieved (and before leaving the warm zone), they must pass through the decon station.
As you can see, you lose personnel quickly, and we haven't even gotten into triage and patient transport.
It may be a good idea to establish an MMST with more than one mass-decon task force. Strategically locate each task force throughout your city. In the event of an attack, one task force could set up and go in service while the others remain on standby in the cold zone for backup support.
Never send response personnel into the hot zone without establishing proper backup, decon and first aid. Set up a separate decontamination station for emergency responders. Decontamin-ating personnel with civilians can cause problems, especially if the decon line is long and you try to funnel contaminated personnel in front of the civilians. This is where support from outside agencies can come into play. Have your hazmat unit or other capable outside agency set up decon for the emergency responders. Utilize police for crowd control. Coordinate with the police department prior to an incident so they know how you plan to operate.
Water-supply problems can occur with decon showers and tent systems. Instruct the decon team members to flush fire hydrants for a few seconds before connecting hoselines and decon equipment. This will remove any debris from the barrel of the hydrant. Most shower heads for decon equipment operate at about 2.2 to 5 gpm. These heads have small orifices designed to reduce water flow into the containment pools, and they clog easily.
Avoid committing your decon team to a water supply inside or close to the hot zone. Hazmat incidents can be very dynamic - the size of a hot zone can change unexpectedly. If that happens, you could be forced to abandon a desperately needed decon station. It is common for terrorists to employ a secondary device. The purpose is to injure rescuers near the hot zone. A secondary device could compromise water supplies by damaging hoselines or water mains.
My advice is to take a wrap on a hydrant in the cold zone and lay line toward your decon station. You can use the water from an engine company booster tank for your initial decon. The booster tank water is clean and readily available. This will buy you the time you need to lay line and hook up to the hydrant. A decon shower that generates a 10-gpm flow can operate for over 45 minutes with a 500-gallon booster tank.
Water runoff from showers can spread contamination in the warm zone. Contain or divert this water from sewers and drains by building dikes around the drain inlets.
Step 7: Testing Your Skills
When your MMST is ready, test its ability to act and to communicate with other agencies. Familiarize yourself with other agencies' abilities and limitations; they have responsibilities at these types of incidents, and your actions may compromise their mission. Getting to know each player face to face prior to an incident will ease tension brought on by an actual emergency.
When all agencies involved believe they are operational, engage your city in a full-scale terrorist exercise. Philadelphia instituted the first full-scale terrorist drill in the nation. The city's MMST performed well, providing decon and medical treatment for over 300 civilians and responders.
Christopher A. Palmisano is a lieutenant in the Philadelphia Fire Department, assigned to the Hazardous Materials Administrative Unit. He has been involved in the planning, training, equipment procurement, development and evaluation of the department's metropolitan medical strike team (MMST) since its inception.
