Major Incidents, Operations, Patient Care, Terrorism & Active Shooter

White Cloud: Responding to suspicious white powder incidents

Issue 2 and Volume 34.

An EMS crew responded to an injury call outside a municipal courthouse and performed their normal “windshield survey” before exiting their vehicle. They noticed that the female victim lying on the ground was covered with a white, powdery substance, and they called for a patrol supervisor and EMS Haz Tac resources.

The crew then donned their PPE and moved forward, having observed no obvious threats or toxidrome. They kept the woman isolated but maintained close visual and verbal contact until the fire department and Haz Tac units arrived.

Bystanders reported the woman was pulled from a taxicab and thrown to the ground by an assailant, who also threw a large quantity of white powder on her.

Was this a biological terror event involving anthrax, ricin or abrin? Was it an assault with a hazardous material? Or was this a hoax perpetrated by some disturbed person or calculating criminal?

After a preliminary determination that the substance was not a caustic or toxic industrial material or radiological source (it was ultimately identified as non-hazardous calcium-based powder), the patient was assisted out of her outer garments and treated for her severe emotional state. She was transported for treatment of her anxiety and potential exacerbation of pre-existing medical conditions.

More than 30 letters containing a suspicious powder were recently mailed to Chase bank branches and federal banking regulators’ offices in nine cities, including Atlanta, Dallas, Denver, New York City and Washington, D.C. It’s believed these incidents were the actions of a lone perpetrator who was angry with the U.S. government over the recent failure of U.S. financial systems. But these attacks could have easily been perpetrated by domestic anti-government groups or an international terrorist organization.

Since the post-9/11 anthrax attacks that killed five people, EMS, fire and law enforcement have responded to more than 30,000 incidents involving suspicious powders, liquids or chemicals. These responses are expensive, time consuming and can often be fraught with inter-agency conflict. They seem to come in waves, with media attention spurring more copycat events. Thus, we must train and be ready for these incidents.

Recommended Course of Action
Arriving EMS providers should perform a scene survey, be alert for the possibility of a secondary device, and exit the area if hazmat involvement is suspected. Crews should immediately request law enforcement and local hazmat resources. They should then begin to set up exclusion zones.

Decontamination of patients varies by threat assessment and local policies. Decon can range from doffing contaminated garments and washing a person’s hands and face to administering a full shower. A 2003 study reported that soap and water work well to eliminate anthrax spores from the hands. The study also looked at the efficacy of the water-free alcohol gels, ubiquitous to the EMS field, to kill the spores or remove them from the skin; it was concluded that these gels were not effective. Respiratory protection for responders is critical.

Many agencies issue CBRN-rated air purifying respirators and filters, as well as NFPA 1999- and 1951-compliant EMS turnout gear. It’s recommended that EMS personnel be trained to the operations level of NFPA Standard 473 (“Standard Competencies for EMS Personnel Responding to Hazardous Materials Incidents”).

EMS providers should act in accordance with their level of certification and agency guidelines. Exposed victims should be isolated in a safe area away from the substance, thereby reducing their dermal and respiratory exposure.

Giving N-95/P-100 masks to these individuals can further reduce their inhalation exposure to the aerosolized product. Take note of and report signs and symptoms of possible toxidrome to the hazmat unit so they can begin identifying the agent and developing a medical management strategy.

Additionally, responders should stay upwind and don PPE in order to avoid exposure. Incident command should have building maintenance shut down the air handling system to help keep the product from spreading.

Threat Assessment
At hazmat incidents, specialized units will perform an assessment of the material and atmosphere, checking for volatility, toxicity, corrosiveness, flammability and radioactivity.

Depending on the time frame and type of technology available to the hazmat unit, they may be able to advise you if the agent falls into a class of material, like the chemical irritant OC or Pepper Spray, or a toxic industrial material or chemical weapon. The next level of the threat assessment will address whether you’re dealing with a biological agent or toxin.

Protein tests in the field setting, however, are inconclusive, and basing action plans on these tests alone is not advised. The potential that a true exposure to a biological agent or toxin has occurred is higher when there’s a distinct threatening message with the powder or substance.

Situations with a lower potential for the presence of a biological agent or toxin include settings in which powder is found without a note or in which a powder comes in an envelope with expected mail that is easy to trace to the sending source.

With the increased frequency of “powder jobs” since 9/11 and the fact that the majority of them end up being hoaxes, responders may become less vigilant. Even though this wasn’t anthrax, the threat of a person cultivating ricin toxin, or the equally potent Abrin toxin, is very real.

In February 2008, ricin made national news with a nearly fatal exposure, albeit self-inflicted. By treating this event as a hazmat/bio-crime incident, the responders were able to protect themselves and the public from harm.

This could have been a person assaulted with a corrosive or other harmful substance requiring gross emergency decontamination. It’s inevitable that agencies and individuals will become more complacent as time passes. It’s also understandable that people don’t want to live in a perpetual state of fear.

But the danger is that, if we don’t respond to every suspicious incident as if it were a confirmed agent release, a lax response to an incident involving a real toxin could result in the unnecessary injury or death of civilians or responders.

1. Schutzer SE, Budowle B, Atlas, RM: “Bio-crimes, Microbial Forensics, and the Physician.” PLoS Medicine. 2(12): e337 doi:10.1371/journal.pmed.0020337, 2005.

2. Hall M: “White Powder Scares cost law enforcement time, money.” USA Today.

3. IAFC: “Model Procedures for Responding to a Package with Suspicion of a Biological Threat.”

4. Weber DJ, Sickbert-Bennett E, Gergen MF, et al: “Efficacy of selected hand hygiene agents used to remove Bacillus atrophaeus (a surrogate of Bacillus anthracis) from contaminated hands.” JAMA. 289(10):1274–1277, 2003.

5. CDC: “Interim recommendations for the selection and use of protective clothing and respirators against biological agents. Emergency Preparedness & Response.”

6. CDC: “Guidance on Initial Response to Suspicious Letter/Container with Potential Biological Threat. Emergency Preparedness & Response.” .

7. Friess S: “Man in Critical Condition in Ricin Case.” New York Times.

For more on EMS and bioterrorism, read “Bioterrorism: EMS Response to Deadly Infections” at