Detailed Lesson Plan s1

Detailed Lesson Plan

Chapter 45

EMS Response to Terrorism

Involving Weapons of Mass Destruction

160–180 minutes

Chapter 45 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines. /
Minutes / Content Outline / Master Teaching Notes /
5 / I.  Introduction
A.  During this lesson, students will learn special considerations related to weapons of mass destruction.
B.  Case Study
1.  Present The Dispatch and En Route information from the chapter.
2.  Discuss with students how they would proceed. / Case Study Discussion
·  What principles from hazardous materials management, scene safety, and mass-casualty incidents apply when responding to a WMD incident?
·  What is the EMT’s role in WMD incidents?
15 / II.  Weapons of Mass Destruction
A.  Definition
1.  Weapons intended to cause widespread, indiscriminate death and destruction
2.  Types—Remember these acronyms.
a.  CBRNE—Chemical, biological, radiological, nuclear, explosive
b.  B-NICE—Biological, nuclear/radiological, incendiary, chemical, explosive
B.  Destructive power
1.  A small amount of a chemical agent may kill hundreds or thousands of people but cause little or no damage to structures.
2.  A small nuclear device can wipe out ten city blocks and damage a much wider area.
3.  Biological weapons are spread by contact and can kill enormous numbers of people.
4.  Conventional explosives are most likely to be used but have the least destructive power.
5.  Nuclear weapons have the greatest destructive power but the least likelihood of use.
6.  Chemical and biological weapons both have a moderate likelihood of use and moderate to high destructive power.
C.  Prehospital management
1.  Similar to that for any mass-casualty incident
2.  All local, regional, and state agencies should have disaster plans.
3.  “All-hazards” approach / Discussion Questions
·  What are the general effects of conventional and nuclear bomb explosions?
·  How are the onset and duration of chemical and biological weapons different from those of more conventional weapons?
Critical Thinking Discussion
·  What are some likely targets of terrorism?
·  What is your personal level of worry about the possibility of terrorism in the United States?
·  What are some ways in which public life has changed since September 11, 2001?
Weblinks
Go to www.bradybooks.com and click on the mykit link for Prehospital Emergency Care, 9th edition to access the Department of Homeland Security website and a web resource on terrorism.
2 / III.  Prehospital Response to Terrorism Involving WMD—Supplies and Equipment
A.  Establish a community response to the disaster.
B.  Each type of WMD incident requires different types of trained personnel, equipment, and supplies.
C.  Communications center must have immediate access to individuals able to deploy equipment, supplies, and personnel.
D.  Neighboring departments must agree to provide equipment, supplies, and personnel. / Teaching Tip
Discuss any known high-risk targets for terrorism in your community.
Discussion Question
Why is it difficult for one community to be completely prepared for all possible threats?
3 / IV.  Prehospital Response to Terrorism Involving WMD—Medical Direction
A.  Establish a plan for how medical direction will reach EMS personnel at the scene.
B.  Establish a way to confirm credentials of EMS personnel from distant areas.
C.  Find a way not to rely on a communication system to provide on-line medical direction; it will probably be overloaded.
D.  Make all protocols standing orders in the case of a WMD incident.
E.  Protocol should address treatment for specific agents.
F.  Triage protocol should ensure that minor injuries and ambulatory patients NOT proceed to hospital (it must be reserved for more serious injuries). / Discussion Question
What are some anticipated issues with medical direction in the response to WMD incidents?
5 / V.  Prehospital Response to Terrorism Involving WMD—Provider Preparation
A.  Personal safety is the first priority of all EMS providers.
B.  Understanding threats and potential consequences of the disaster is vital.
C.  Rushing into a scene can cause the death of many rescuers (a possible secondary objective of the terrorists).
D.  Be aware of the various agents that can be used as WMD.
E.  Do not proceed without specific guidelines on triage and management of these patients.
F.  Know potential dangers to your health both during the incident and after it is over. / Discussion Question
In what ways must EMTs be prepared for response to WMD incidents?
5 / VI.  Prehospital Response to Terrorism Involving WMD—Responding to the Scene
A.  Recognize the incident and the WMD involved.
B.  Employ the same command system as for any multiple-casualty incident.
C.  Keep the rules for responding to a hazardous materials incident in mind.
D.  Establish an EMS command center if you are the first-arriving EMS crew.
E.  Be wary of secondary explosions when conventional weapons are used.
10 / VII.  Prehospital Response to Terrorism Involving WMD—Issues of Scene Safety
A.  Identify the specific weapon involved.
1.  Conventional, chemical, and biological weapons
a.  Small region of impact
b.  Extreme strain on EMS system and medical care
c.  Medical facilities and personnel primarily intact after attack
d.  Chemical weapons may leak gas or aerosols and render the environment toxic.
e.  Symptoms of exposure to chemical weapons
i.  Respiratory distress
ii. Dyspnea
iii.  Chough
iv.  Burning chest
v. Burning eyes
vi.  Excessive salivation
vii.  Loss of bowel/bladder control
viii.  Tearing
f.  Exposure to biological weapon usually predates signs or symptoms by several days.
g.  Patient will therefore contaminate EMS crew and hospital personnel before agent has been identified.
2.  Nuclear weapons
a.  Concentric rings of total destruction, plus death and injury
b.  Difficult access to scene
c.  Destroys everything inside ring of impact.
i.  Emergency services
ii. Health care services and facilities
iii.  Shelters
iv.  Medical supplies
v. Food and clean water
vi.  Electrical equipment
vii.  Communications systems
d.  Radioactive fallout begins about one hour after detonation and continues for days or weeks.
B.  Approach site of suspected chemical, biological, or nuclear weapon attack from upwind.
C.  If the site is indoors or in a confined space, only specially trained responders wearing proper protection should enter.
D.  Stay away from WMD scene until WMD has been identified and you can take proper precautions.
E.  Employ incident command system (ICS) to respond to scene.
F.  Establish sectors of operation.
G.  Coordinate with law enforcement; contact immediately if you locate a suspected perpetrator among the patients.
H.  Enter scene from a single staging point.
I.  Establish an escape plan and make sure everyone is aware of it. / Discussion Questions
·  What are some specific considerations for scene safety in the response to WMD incidents?
·  What clues can help you determine what kind of weapon is involved?
5 / VIII. Prehospital Response to Terrorism Involving WMD—Role of the EMT at the Terrorist Incident Involving WMD
A.  Scene size-up
1.  First unit to arrive usually takes this role.
2.  Establish incident command.
3.  Size up the scene (360-degree assessment).
4.  Evaluate the need for additional resources.
5.  Begin to communicate essential information.
6.  Estimate the number of patients involved.
7.  Implement incident plan and protocol as soon as possible.
B.  Sector leader or officer—Usually second or third unit to arrive
C.  Triage—Usually units that arrive after sector officers are all assigned
D.  Overall goal is to do the greatest good for the greatest number of people. / Weblink
Go to www.bradybooks.com and click on the mykit link for Prehospital Emergency Care, 9th edition to access a web resource on the adoption of standards for hazardous materials and weapons of mass destruction.
2 / IX.  Conventional Weapons and Incendiary Devices—Explosives
A.  Explosives ignite fuels that burn rapidly, causing hot gas to displace air violently, creating a blast.
B.  This blast moves out in all directions at supersonic speed, causing blast injuries.
C.  The farther you are from the explosion, the less likely you are to be injured.
D.  Barriers between you and the explosion will protect you.
E.  If the explosion occurs in an enclosed space, the effects are amplified. / Teaching Tip
Identify any high-risk facilities in your community, such as fuel refineries/storage facilities or fertilizer manufacturing/storage facilities.
Discussion Question
Why are conventional weapons and incendiary devices the most commonly used WMDs?
2 / X.  Conventional Weapons and Incendiary Devices—Primary, Secondary, and Tertiary Effects
A.  Primary effect—Blast of the explosion
B.  Secondary effect—Flying debris, shrapnel, and other projectiles cause significant penetrating or blunt trauma.
C.  Tertiary effect—Explosion propels body against ground or objects, causing blunt trauma. / Discussion Question
What types of injuries are produced in each of the three phases of a blast?
1 / XI.  Conventional Weapons and Incendiary Devices—Body Position
A.  Victims standing or lying perpendicular to blast will suffer greatest injuries.
B.  Victims lying directly toward or away from the blast will suffer least injury.
C.  If you have warning of a blast, drop to a prone position facing away from the detonation.
10 / XII.  Conventional Weapons and Incendiary Devices—Types of Injuries
A.  Lungs
1.  Altered mental status
2.  Dyspnea
3.  Blood-tinged sputum
4.  Respiratory distress
5.  Chest pain
6.  Stroke-like signs and symptoms
7.  Pneumothorax or tension pneumothorax
8.  Injury to alveolar-capillary wall
B.  Abdomen
1.  Bleeding or perforation of the bowel
2.  Evisceration
C.  Ears
1.  Ruptured eardrum
2.  Fracture of small bones inside ears
3.  Temporary or permanent hearing loss
D.  Crush injuries (from being buried or trapped under heavy debris)
1.  Direct blunt and/or penetrating trauma
2.  Respiratory and eye injuries from dust and smoke
3.  Crushed tissue produces harmful byproducts.
E.  Shrapnel injuries
1.  Solid organs are compressed and stretched.
2.  Hollow organs rupture and leak contents into surrounding cavities.
3.  Connective tissue injuries are usually limited to shrapnel pathway.
4.  Bones fracture when struck. / Knowledge Application
Students should be able to apply the information in this section when responding to potential WMD incidents.
Weblink
Go to www.bradybooks.com and click on the mykit link for Prehospital Emergency Care, 9th edition to access a web resource on blast injuries.
5 / XIII. Conventional Weapons and Incendiary Devices—Incendiary Devices
A.  Types of devices designed to burn at extremely high temperatures
1.  Napalm
2.  Thermite
3.  Magnesium
4.  White phosphorus
5.  Gasoline, propane, or natural gas
B.  Primary injuries—Burns
C.  How to treat
1.  Use burn-depth classification system and rule of nines to assess injury.
2.  Pay particular attention to airway and ventilation.
3.  Dress the burns. / Discussion Question
What types of agents are used for incendiary devices?
Class Activity
Assign students to do a “windshield survey” of the community over the next week and report back any facilities that could play a role in supplying materials needed to create a WMD or that could be a target of a WMD.
10 / XIV.  Chemical Agents—Properties of Chemical Weapons
A.  Forms of chemical weapons
1.  Aerosol form—Liquid chemicals stored in munitions convert on explosion
2.  Gas form—Affected by warm temperatures
a.  Hydrogen cyanide
b.  Chlorine
c.  Phosgene
3.  Liquid form—Nerve and mustard agents
B.  Terms to remember
1.  Volatility—Tendency of a chemical to evaporate
2.  Persistence—Chemical’s resistance to evaporation
C.  Effects on the person exposed
1.  Aerosol, solid, vapor, or gas agent enters the body through the respiratory tracts, skin, and eyes.
2.  Liquid agents enter the body through the skin and eyes.
3.  Ingestion of chemicals in food is possible but rare. / Teaching Tip
Identify any potential sources of chemical agents in your community.
20 / XV. Chemical Agents—Types of Chemical Agents
A.  Nerve agents
1.  Effects on the body
a.  Affects nervous system, airway, and respiratory system
b.  Interferes with brain’s ability to function
2.  Signs and symptoms
a.  Rapid loss of consciousness
b.  Seizures
c.  Apnea
d.  Difficulty in concentrating
e.  Inability to sleep
f.  Impaired judgment
g.  Depression
h.  Respiratory failure
i.  Obstructed airway
j.  Drooling
k.  Other signs and symptoms
i.  Acronym SLUDGE: salivation, lacrination, urination, defecation, gastric distress, emesis
ii. Tachypnea and tachycardia or bradycardia and normal blood pressure
3.  Emergency medical care
a.  Establish an airway.
b.  Provide positive pressure ventilation at 12 ventilations per minute (adult patient).
c.  Suction the airway to clear secretions if necessary.
d.  Position the patient in lateral recumbent position and monitor closely.
e.  Administer antidote: atropine and pralidoxime (Protopam) (carried by most EMS systems)
f.  Never hesitate to administer the antidote if a patient has been exposed to nerve agents.
g.  To combat seizures, administer diazepam (Valium).
h.  Cover wounds, keep the patient warm, and transport as soon as possible.
B.  Vesicants
1.  Signs and symptoms (may be delayed if mustard gas is the agent)
a.  Burning, redness, blistering, and necrosis of skin
b.  Stinging, tearing, and development of ulcers in the eyes
c.  Shortness of breath, coughing, wheezing, pulmonary edema
d.  Nausea and vomiting
e.  Fatigue
2.  Emergency medical care
a.  Irrigate with water or chemical decontamination kit.
b.  Manage the blistering as chemical burns.
c.  Apply a dry sterile dressing after flushing.
d.  Patch eye injuries after flushing.
C.  Cyanide
1.  Signs and symptoms
a.  Anxiety
b.  Weakness
c.  Dizziness
d.  Nausea
e.  Muscular trembling
f.  Tachycardia
g.  Tachypnea
h.  Pale, cyanotic, or normal color skin
i.  Apnea
j.  Unresponsiveness
2.  Emergency medical care
a.  Manage the airway.
b.  If breathing is inadequate, provide positive pressure ventilation.
c.  If breathing is adequate, provide oxygen by nonrebreather mask at 15 lpm.
d.  Administer antidote: CyanokitÒ (hydroxcobalamin).
D.  Pulmonary agents
1.  Signs and symptoms
a.  Tearing
b.  Runny nose