Major Incidents, Operations, Patient Care, Training

Preparing for a Biological or Nuclear Event

Issue 1 and Volume 36.

We frequently hear such terms as planning, preparedness, response and recovery intertwined with many aspects of EMS. When turned into processes, these terms become essential to our daily responses. EMS agencies should review how often their planning encompasses emerging threats, such as biological and radiological/nuclear events, because intelligence experts believe potential terrorist attacks could involve these elements to some degree in the future.

Terrorist attempts to produce or use B. anthracis have occurred three times over the past 17 years. Here in the U.S., the 2001 letter attacks caused 22 infections, which resulted in five deaths, crippled mail delivery in several cities and cost more than $1 billion dollars for decontamination according to the Weapons of Mass Destruction (WMD) Commission Report.(1)

This report also noted that had one gram of the same anthrax used in the 2001 attacks been disseminated outdoors in an urban area, up to 1,000 people could have become infected. This explains the vast movement for preparedness in the EMS community. So you should evaluate and address, outside of chemical and explosive incidents, how prepared your agency is for biological, radiological and nuclear events. Are you planning and preparing for these hazardous substance emergencies?

In a January 2009 Washington Times article, “Terror Medicine can Save Lives,” author Leonard A. Cole makes an astounding statement regarding preparedness. Cole dispels critics’ beliefs that bio-security systems waste taxpayers’ dollars and don’t work, stressing the importance of education and training in terror medicine. The global proliferation of terrorism in and of itself warrants enhanced preparedness, Cole writes. “It [terror medicine] involves anyone who would be called to service during or after a terror incident—from emergency responders to long-term caregivers. Yet ironically, most physicians and other health (EMS) providers, let alone members of the public, are still unfamiliar with many of its features.” This perspective echoes across much of the medical profession and is imbedded with many issues that directly affect EMS.

A Systemic Approach
EMS response to biological or radiological events should have a comprehensive systematic approach to manage a hazardous event. When responding to either a biological or a radiological event, always consider the following recommendations:

1. Scene safety and assessment prior to your arrival (via dispatch and on-scene reports), your initial on-scene observations before exiting your vehicle and responder and bystander information available to you once you exit
your vehicle;
2. Initial and continual patient assessment, decontamination and treatment of all affected persons; and
3. Patient transport to, and advanced notification of, the appropriate treatment facilities. (And, don’t send the disaster [contaminants] to the hospitals)

The systems approach to any hazardous event should be approached and tailored to each specific condition within the “framework” of prehospital and in-hospital response. The framework defines the characteristics and mechanisms of the response and recovery phase. Differences in the framework will influence emergency response planning, organization, training, equipment, operational procedures and coordination requirements.

In general, several key differences and considerations affect the system’s approach to creating a framework. For example, not all situations may be recognizable as a terrorist event until an appropriate investigation is conducted. Multiple casualties may be involved. The cause of the incident or deaths involved with it may not be determined until testing has been confirmed.

Note that first responders are placed at a higher risk of becoming a casualty because many biological or radiological contaminates aren’t easily recognized or detected. In addition, first responders may not have detection equipment available. Contamination of critical infrastructure and large geographical areas may result.

Exposed people may unknowingly carry contaminants through common public areas, such as transportation systems, businesses, schools and hospitals. Likewise, the scope of the event may expand at a rapid rate across state and local jurisdictional boundaries into areas with limited medical resources. Airborne contaminants will flow with the air currents, and if disseminated properly, may carry to great distances from their point of origin. Therefore, time becomes the enemy for providers responding to the event. Remember that treatment modalities will differ between types of agents and recommended course of antidote or medication.

It’s also important to remember that a strong reaction from the public will ensue. The thought of exposure to biological or radiological material is enough to cause fear and panic in the general public. A biological or radiological event will likely produce a 4:1 ratio of psychological casualties (i.e., “worried well”) to actual injured or exposed victims. This represents a serious impact on first responders and hospitals.

Just as differences exist within a system’s approach framework commonalities also exist that are consistent within a systems approach and serve as the template for tactical operations. The following commonalities affect the systems approach framework:

> Scene size-up;
> Initial assessment;
> Focused history and physical exam (trauma or medical);
> Intervention (decontamination);
> Ongoing assessment; and
> Transport.

EMS providers should expand their knowledge of biological and radiological contaminants as part of ongoing continuous education and for application into a framework for a specific event, whether biological or radiologic.

For a biological event, knowledge of agents and their characteristics is critical, from sizing-up a scene through to transporting patients to an accepting facility.

In the case of a radiological event, consider and detail your systems approach to deal with such issues as internal/external contamination, personal protective equipment (PPE), exposure limits, decontamination process and interpretation of clinical signs, which will be critical for the first responder to react in the most effective and efficient manner.

Biological Agents
Biological agents are defined as microorganisms or toxins that can cause disease processes. Most commonly, the biological agents are bacteria, viruses or toxins. Virtually any biological material could be weaponized and disseminated; some materials are just more effective than others. It’s important to understand the differences between a bacterium, virus and toxin because these differences can indicate the ease of manufacture, availability of antidotes, and, to some extent, their effectiveness.

A bacterium is a small microorganism that can live outside a host cell. If provided the proper environment—temperature, moisture and food—these cellular organisms can survive on their own and reproduce by simple cellular division. Many of the bacteriological agents respond to specific antibiotic therapies and, for the most part, are treatable conditions if detected early.

A virus is an organism that requires a host cell to live and reproduce, and it’s intimately dependent on the cell it infects. The diseases that viruses produce generally don’t respond to antibiotics, but they may be responsive to a few antiviral compounds.

In contrast to bacteria and viruses, toxins are non-living organisms. They’re poisonous chemical compounds produced by or derived from another living organism. The producing living organism could be a plant, animal or microorganism. Examples include ricin, which is derived from the castor bean; mycotoxins, which are produced by fungi, or the botulinum toxin, which is produced by the bacterium clostridium botulinum.

Anthrax (bacillus anthracis) is a naturally occurring zoonotic disease, which can move through the animal-human barrier. It’s found in many countries and labs worldwide. Carriers of anthrax include cattle, sheep and horses, and these carriers can infect humans naturally, particularly those who handle hair, wool, hides or excrement of infected animals.

The most common human form of anthrax is the cutaneous form, also known as Woolsoter’s Disease. EMS providers should be aware that this condition is found in people who have had open sores or lacerations contaminated with anthrax spores during the handling of hides or shearing of wool. The gastrointestinal form of anthrax, which is a sporulating bacterium, also can be transmitted by contaminated meat; however, this is rare. It’s important to note that such sporulating bacteria produce a seed-like shell that makes them resistant to breakdown by ultraviolet light and other insults. Therefore, areas contaminated by anthrax can remain contaminated for long periods of time, which is why special sporucidal soaps are recommended as decontamination materials.

EMS providers should know that the most concerning form of anthrax is the
inhalational form, which is lethal. If anthrax is aerosolized in small enough particles (e.g., 3 to 5 microns in diameter), it can be inhaled and retained in the deeper portions of the respiratory tract and may be contracted. This is why all vehicles should have respirators immediately available to each responder arriving on scene.

With all forms of anthrax, antibiotic therapy works well to counteract the effects, provided that antibiotics are given early enough in the disease process. The problem with inhalational anthrax, however, is that it commonly presents as nonspecific respiratory symptoms and may not be recognized as anthrax.

Therefore, the start of antibiotics may be delayed, and if they’re not started before the “anthrax eclipse,” 12 to 36 hours after exposure, such therapy may have little benefit.

EMS providers should remember that during the anthrax eclipse period, recovery often seems to be occurring, and the patient feels better. However, shortly after the eclipse begins, the symptoms return. Death follows in two to three days. Anthrax is an infectious disease, not a communicable one, meaning it isn’t transmitted from an exposed or infected patient to another person; therefore, health-care providers are not at risk for infection from direct patient care.

Preparing for a Nuclear Event
The three main types of nuclear radiation emitted from radioactive materials are alpha, beta and gamma. Alpha, which are the heaviest and most highly charged of the nuclear particles, can’t travel more than a few inches in the air and are stopped by the outermost layer of dead skin that covers the body.

Beta particles are smaller and travel much faster than alpha particles, but they generally don’t penetrate far enough to reach the vital inner organs. However, if the skin is exposed to large amounts of beta radiation for long periods of time, skin burns may result.

Gamma rays are a type of electromagnetic radiation transmitted through space in the form of waves. They’re pure energy and the most penetrating type of radiation. They travel great distances, penetrate most materials, and can attack all tissues and organs. Acute radiation sickness presents distinctive, short-term symptoms, including skin irritation, nausea, vomiting, high fever, hair loss and dermal burns.

The aim of malevolent acts with radioactive material is to create a significant economic, political or health event, including psychological stress. The casualties in such incidents are likely to be members of the public. Depending on the event, the number of affected people could vary from a few to mass causalities. Some scenarios could result in received doses high enough to cause Acute Radiation Syndrome. Radiation injuries could also be combined with conventional injuries.

Possible scenarios that may result in injuries include the use of radiological dispersal devices, radiological exposure devices or improvised nuclear devices or from an attack on the transport of radiological material, nuclear installation or the contamination of food and/or water.

Dose rates will vary on scene regardless of the scenario, and it’s unlikely that experienced radiation protection personnel will be available early in an incident to take dose measurements. Therefore, first responders need to have a method to assess their individual exposure to external radiation during the initial stages of the response. Providers should be issued and trained in how to operate radiation detection devices that will indicate dose rates or total cumulative external doses.

They should also be aware that such devices will not detect non-penetrating doses of radiation.

Moving Forward
To prepare for a biological or nuclear event, it’s wise to talk with your local, regional and state officials and experts regarding these topics. Most states and many large cities operate with or are linked to fusion centers, which provide analysis for sensitive high-risk subject matter and disseminate information to emergency management, law enforcement, fire, EMS and public health entities.

EMS organizations that maintain subject matter expertise in natural disaster preparedness for such events as hurricanes, earthquakes and floods can also transfer their expertise to the applicable areas for most incidents. Biological and radiation/nuclear events harbor serious consequences. By gaining knowledge in risk identification and training, you can base your capability for response if such an event were to occur. Remember: Identify your risks; own your risks; communicate your risks; take action. JEMS


  • 1. Carder T. Handling of Radiation Accident Patients by Paramedical and Hospital Personnel. CRC Press, Inc., Boca Raton, Fla. 1995.
  • 2. Chemical/Biological Incident Handbook. The Director of Central Intelligence. Interagency Intelligence Committee on Terrorism, Community Counterterrorism Board. 1995.
  • 3. Commonwealth of Virginia Emergency Operations Plan. Virginia Department of Emergency Services. 2007.
  • 4. Johnson S, Lewis W. Weapons of mass destruction: New perspectives on counterproliferation. U.S. Government Printing Office, Washington, D.C. 1995.
  • 5. Medical Management of Biological Casualties Handbook 2nd Edition, U.S. Army Medical Research Institute of Infectious Diseases, International Medical Publishing, Inc. 1996.
  • 6. U.S. Dept. of Health and Human Services Public Health Services, National
  • Institute for Occupational Safety and Health. NIOSH Pocket Guide to Chemical Hazards, Centers for Disease Control & Prevention. 2007.
  • 7. U.S. Army Chemical and Biological Defense Command (CBDCOM),
  • 8. Viccellio P. Handbook of Medical Toxicology. Little, Brown & Company,
  • Boston. 1993.

    This article originally appeared in November 2010 JEMS as “Unseen Threats: Preparing for a biological or nuclear event.”