Stacy Nadler EMS 6017 NYMC SPH

FINAL EXAM 2011

1. Describe two of the characteristics that define terrorism. (4pts.)

The unlawful use of force or violence against persons or property to intimidate or coerce a government, the civilian population, or any segment thereof, in furtherance of political or social objectives. A terrorist act is generally political, and violent. The victim and the audience are not generally the same, the randomly or symbolically selected target is used to convey a political message to another audience, usually the government, to try to affect their behavior. It is also a deliberate targeting of innocents.

2. List 2 incidents of domestic and 2 incidents of international terrorism against the United States. (4)
Domestic: Oklahoma city bombing, Colombine Shooting International: Attacks of 9/11, October 12, 2000, terrorists attacked the USS Cole, a warship that was refueling in a port in Yemen, a country located on the Arabian Peninsula. Seventeen American sailors were killed In Addition: World Trade Center, New York City (1993) Animal Liberation Front arson attack, Michigan (1993) Attempted bombing of IRS facility (1995) Ricin possession, Virginia (1995) Oklahoma City bombing (1995) Amtrak derailment, Arizona (1995) Washington State Militia and Freeman Group arrested on Federal conspiracy charges (1996) Bomb attack on FBI Field Office, Texas (1996) Numerous bomb attacks, Atlanta (1996-97)

3. Describe the 4 major categories for weapons of mass destruction with examples of each (10).
Chemical, biological, radiological/ nuclear weapons and explosives (CBRNE). Chemical: 1995 sarin attack in Tokyo subways, and the 2001 anthrax attacks. Biological: The use of viruses or super-viruses (such as a super flu) released in an act of terrorism to cause death. As read about in out assigned reading the bioterrorist next door Radiological/Nuclear: Radiological deals with radiation or material that emits radiation. Davy Crocket round or a Russian suitcase bomb.

Nuclear refers to processes that involve splitting a nucleus (fission) or combining nuclei of atoms (fusion). Jet crash into a nuclear power plant, or other intentional attack on a nuclear reactor to release nuclear substances that would contaminate a large area surrounding the reactor. Explosives: Propellants can be released as heat, sound, or light. Most explosives are heat, C4, Dynamite, and Nitroglycerine are a few examples. There is a difference between small and large scale bombs. There are military grade bombs and homemade explosives such as letter bombs or car bombs.

4. Describe 4 areas in which the Public Health system plays a role in preventing or responding to terrorism. (10)
The Public health systems role in preventing and responding to an act of terrorism is really about how they calculate risk, mitigate, prepare and respond. Calculating risk for a specific area is generally done by the epidemiologists of the public health system. They will use information about the area of interest, such as past history, types of businesses and recreation areas that could possibly become a target. Part of Mitigating is to take the risk into consideration and to create plans and protocols that govern how things should go in the case of an attack. Also to educate the public and the healthcare workers on what those protocols are. In an are such as NYC there would possibly be protocols governing building structure and transportations systems, also evacuation routes would be important to have planned. Preparations are important everything discovered as a risk and that the mitigation process discovers a possibly problem needs a plan. Some of examples of these plans are the communication systems and how they can be kept open in the case of widespread outages. Utilities and how we can insure that there is power and fuel and water particularly to hospitals and to the designated areas that would be EOC. Response, knowing the numbers and types of available emergency responders and medical personnel needed to respond and keeping track of where they all are and where they should be going. Besides the need for direct patient care it may also be necessary to deploy Hazardous Materials Teams, Bomb Teams, Urban Search & Rescue, Medical Reserve Corps.

5. What are the key elements or functions of emergency management? Describe each with examples as applied to the public health sector. (16)
Emergency management: to protect life, then property, then the environment. As a result, when conducting emergency planning activities, the health and medical needs if the population are among the most significant and are considered the basic health and human needs including sheltering, mass care, sanitation, environment health, food and water, and other essential services. In addition, as public health professionals, we also believe that population health activities include the mitigation of increased morbidity and mortality during and following a disaster, act of terrorism, or public health emergency.

Communicate Alert to Key Stakeholders, Develop Public Announcements, Review Emergency Response Plan with County Health and Emergency Management Staff, Ensure that Medical Surge Capacity Exists Including Medical Supplies, Vaccines & Antibiotics, Special Needs and Vulnerable Population Assistance, Special Needs and Vulnerable Population Assistance, Environmental & Occupational Health, and Mental Health Services Risk analysis Mitigation Preparedness Response Recovery Risk = hazard threat x vulnerability Determination of risk prioritizes our plans and allocates scarce resources to the best possible use Mitigation: Actions taken to eliminate hazards, harden targets, strengthen existing systems, add redundant systems Example: Risk analysis for fire hazard shows hospital is vulnerable due to pre-1940 electrical system. Mitigation: replace electrical panels with sensitive breaker fuses and add new fire detection system Preparedness: The activities that build capabilities and capacity to address the threat or hazard Example: For an identified risk of chemical attack, train personnel to HAZMAT awareness level with local emergency responders; hold drills and exercises with them to test the emergency operations plans Response: The actions taken to prevent, decrease, or eliminate the impact of the hazard once it occurs Example: release of poisonous gas in the emergency room. Response by HAZMAT trained personnel to evacuate and decontaminate patients and seal off the area Recovery: Activities designed to return to normal status Includes financial accounting and recuperation Personnel rehabilitation Equipment and supplies replacement Facility rehabilitation

6. Describe two emergency management roles of the NYC Department of Health in the years following the attack on the WTC on 9/11/01. (8)
An emphasis on planning, response, and training for HCFs. GPS systems for emergency response vehicles. Credentialing for volunteers. Patient locator databases. Aftercare for disaster responders.

New York City AWARE is a program designed to help keep New York City residents up to date about the New York City Department of Health and Mental Hygiene's preparedness for possible public health emergencies, including those caused by terrorism. Keeping the public adequately informed is a major aspect of emergency management. It helps people be aware of the necessity to evacuate or stay in place, as well as how to be prepared with their own personal emergency management plan. NYC Healthcare PREPARES is a DOHMH web site dedicated to healthcare emergency preparedness. Healthcare facilities and emergency planners from New York City and from across the country may access protocols, guidance, templates, and other tools useful for preparedness. Updates to new protocols, guidance documents and a calendar of upcoming events will occur frequently as new materials become available. Being sure that all aspects of emergency medical services are all in coordination and on the same page as far as protocol during an emergency is key. This program helps to keep first responders and hospitals trained and in sync. This program also runs drills and keeps up to date information to be sure that in the event of an emergency all aspects of keeping people safe and healthy are covered to the best of the ability of the city.

7.

Describe the structure of the Incident Command System, defining the key roles and for what each is responsible. (10)
COMMUNICATIONS PERSONNEL NOTIFICATIONS STAFFING AND COMMAND PRE-WRITTEN TASKS, MAPS, GRAPHICS SPECIALIZED EQUIPMENT INTEGRATION OF OUTSIDE PERSONNEL CREDENTIALING OF VOLUNTEERS CONTAMINATION OPERATING OUTSIDE THE USUAL FACILITY

Hospitals need to build a dynamic and functional Emergency Operations Plan that fully incorporates the Incident Command System (ICS). The ICS is a standardized, incident management system that enables hospitals and others to organize resources, staff and facilities in order to remain operational during an emergency and promote the restoration of day-to-day operations. This enhances compliance with national standards and hospital accreditation requirements, such as, Surge capacity, mass casualty, hospital evacuation, hazardous materials incidents, severe weather plan, home health and hospice, and facility management. The purpose of the Emergency Management Plan is to define the Emergency Management Plan, which can respond effectively to events that pose an immediate danger to the health and safety of patients, staff, and visitors. The Emergency Management Plan consists of a number of procedures designed to respond to those situations most likely to disrupt the normal operations of the hospital and return the hospital to a normal status. An Emergency Management Plan is meant to be an all hazards plan and is designed for each emergency identified in the Hazards Vulnerability Analysis (HVA) which could impact

the operation of the hospital. The Emergency Management Plan is developed to assure availability of resources for the continuation of patient care during an emergency. The Plan also addresses the medical needs of victims of a hospital or community based incident. Having a hospital administrator with the skills, knowledge, and ability who also has an understanding of the principals of EM is important. This person should be held accountable and have a firm knowledge of the assignments of these duties. This hospital leader must head the effort by supporting the role of emergency management in a style that is unyielding to the entire hospital. This may be done through regular communications, preparedness drills, and active involvement in the community. Annual evaluations may also be done to examine the scope, objectives, performance, and effectiveness of the Emergency Management Plan.

8. What kind of materials could be used to make dirty bombs, and where could they be found? (4)
Uranium (nuclear power plant fuel and nuclear weapons) Plutonium (nuclear weapons) Americium (smoke detectors) Thorium (high-temperature metals)

9. Define a risk analysis and why it is done (6). Conducted to determine the relative seriousness of hazard risks
Risk:

A measure of the probability and severity of a hazard to cause harm

Hazard x Vulnerability = Risk How many excess cases of outcome A will occur in a population of size B due to a hazard event C of severity D? Creating a risk matrix Comparing hazard risks against levels of risk estimated during the analysis process with previously established risk evaluation criteria Evaluating risks according to the SMAUG methodology

It is done for: Preventing or removing the hazard Moving away from the hazard Public information and education Early warning systems Reducing the impact of the disaster Increasing the local capacity to respond

Seeks to determine the number of injuries, the number of deaths, the cost of direct damages to property and infrastructure, and the indirect costs associated with the disaster Identify which risks require referral to other agencies Identify which risks require treatment by the disaster managers Further evaluate risks using judgment based upon available data and anecdotal evidence, to further determine the accuracy of the final risk value recorded.

10. Describe two key functions of mass fatality management, giving examples of how they were done in past disasters. (8)
Defined as a Response Mission within the US DHS Target Capabilities List as the capability to effectively perform: Investigation, documentation, recovery, transportation, mitigation of any hazards and storage of human remains (HR) to include all related forensic and physical evidence (PE) Identification of decedents using scientific means Certification of the cause and manner of death Processing and return of decedents and PE to the NOK Provision of legal, compassionate and culturally competent services to families within the context of a Family Assistance Center (FAC) In past disasters these duties were not always done correctly and efficiently. In the aftermath of the WTC attacks Fire fighters were identified and called out based on the name on their gear, this information was then made public in the media and to the families of the victims. Unfortunately, some of that information was incorrect, being many of the fire fighters had run into firehouses and thrown on any available gear to respond quickly. Also, some victims were pulled out and although they were taken to a specific off site mortuary which is part of an appropriate plan their jewelry and personal belongings were taken off of the bodies and put to the side for safe keeping this in the long run was a mistake that caused many problems in victim identification because they were not processed and categorized correctly. Another example also from WTC attacks was the Certification and cause and manner of death. In many cases the families of victims could not pay their mortgages and other bills and could not collect pensions and insurance money to help, due to their missing family members had not been found or any remains identified as being them. The New York City Legal and Judicial community intervened and instituted Death Certification by Judicial Decree based on sworn affidavits and evidence in the absence of a body.

11. Perform a general risk analysis for the School of Public Health building at NYMC. Calculate 4 risks, using one of the formats described in class or in your readings (use a scale of 1 to 5 for each factor). Assume a solid infrastructure. (10)
PROBABILITY HUMAN IMPACT PROPERTY IMPACT BUSINESS IMPACT PREPAREDNESS INTERNAL RESPONSE EXTERNAL RESPONSE RISK

EVENT Electrical Failure Medical Gas Failure Fire, Internal Hazmat Exposure, Internal AVERAGE SCORE

2 1 2 2 1.75

3 1 2 3 2.25

2 1 3 2 2.00

2 2 2 3 2.25

1 1 1 3 1.50

2 1 1 2 1.50

1 1 1 2 1.25

41% 13% 37% 56% 2%

7 43

RISK = PROBABILITY * SEVERITY 0.02 0.12 0.13

12. Choose one hazard for a hospital emergency management plan: pandemic influenza or category 4 hurricane. Write a brief plan for dealing with either of those hazards, identifying 5 key areas for your response plan. (10)
Influenza: Hospital surveillance Mechanisms for conducting surveillance in emergency departments to detect any increases in influenza-like illness during the early stages of the pandemic Mechanisms for tracking emergency department visits and hospital admissions and discharge of suspected or laboratory-confirmed pandemic influenza patients. This information will be needed to: 1) Support local public health personnel in monitoring the progress and impact of the pandemic, 2) assess bed capacity and staffing needs, and 3) Detect a resurgence in pandemic influenza that might follow the first wave of cases. Updated information on the types of data that should be reported to state or local health departments and plans for how these data will be collected during a pandemic. Communications

 Assign responsibility for external communication about pandemic influenza; identify a person responsible for updating public health reporting, a clinical spokesperson, and a media spokesperson. Identify points of contact among local media representatives and public officials and community leaders. Education and training Each hospital should develop an education and training plan that addresses the needs of staff, patients, family members, and visitors. Hospitals should assign responsibility for coordination of the pandemic influenza education and training program and identify training materialsin different languages and at different reading levels, as neededfrom HHS agencies, state and local health departments, and professional associations (see Appendix 1). Surge capacity Healthcare facilities should plan ahead to address emergency staffing needs and increased demand for isolation wards, ICUs, assisted ventilation services, and consumable and durable medical supplies. Staffing Estimate the minimum number and categories of personnel needed to care for a single patient or a small group of patients with influenza complications on a given day. Determine how the hospital will meet staffing needs as the number of patients with pandemic influenza increases and/or healthcare and support personnel become ill or remain at home to care for ill family members. Create a list of essential-support personnel titles (e.g., environmental and engineering services, nutrition and food services, administrative, clerical, medical records, information technology, laboratory) that are needed to maintain hospital operations. Consult with the state health department6 on plans for rapidly credentialing healthcare professionals during a pandemic. Identify insurance and liability issues related to the use of non-facility staff. Bed capacity Review and revise admissions criteria for times when bed capacity is limited Develop policies and procedures for expediting the discharge of patients who do not require ongoing inpatient care. Work with home healthcare agencies to arrange at-home follow-up care for patients who have been discharged early and for those whose admission was deferred because of limited bed space. Discuss with local and state health departments how bed availability, including available ICU beds and ventilators, will be tracked during a pandemic. Develop Mutual Aid Agreements (MAAs) or Memoranda of Understanding/Agreement (MOU/As) with other local facilities who can accept non-influenza patients who do not need critical care. Consumable and durable supplies Consider stockpiling enough consumable resources such as masks for the duration of a pandemic wave. Anticipate needs for antibiotics to treat bacterial complications of influenza, and determine how supplies can be maintained during a pandemic. Establish contingency plans for situations in which primary sources of medical supplies become limited. Consult with the local and state health departments about access to the national stockpile during an emergency.

Mortuary issues: To prepare for the possibility of mass fatalities during an influenza pandemic, hospitals should do the following: Assess current capacity for refrigeration of deceased persons. Discuss mass fatality plans with local and state health officials and medical examiners. Work with local health officials and medical examiners to identify temporary morgue sites. Determine the scope and volume of supplies (e.g., body bags) needed to handle an increased number of deceased persons.