OVERVIEW

Forensic knowledge, skills, and abilities have become an essential part of the acumen of emergency department (ED) personnel. With the ever-present threats of terrorism, it is imperative that physicians and nurses are aware that ill and injured patients who present for treatment may have been victims of a terrorist act. On their bodies or clothing, there may be vital evidence regarding the attack. This means that from the first encounter with an injured patient, one should begin to ask the questions aimed at distinguishing accidents from intentional acts meant to harm individuals or groups. When patients arrive with unexplained respiratory complaints, neurological or gastrointestinal phenomena, skin rashes, or unusual cutaneous lesions, staff members should consider the potential of chemical or biological agents. When the first patient arrives with a strange battery of signs and symptoms, it is easy to assume that the individual has an isolated, albeit unusual, condition. However, when others follow with similar states, the ED should convert its operations from the routine flow, and assume a disaster-like response mode until chemical, biological, or other types of terrorism can be ruled out. A part of this contingency response involves protecting the ED environment and its resources, including personnel.

It is beyond the scope of this article to discuss all potential terrorism acts that could generate patients for the ED. However, the approach to any act of known or suspected terrorism must include a sense of urgency about capturing and preserving forensic evidence, while always remaining focused on the treatment and well-being of the patient victim. Evidence that is carefully documented, collected, and transmitted to the proper investigative authorities will assist in deciphering specific acts of terrorism and perhaps lead to the identification of perpetrators of terrorist acts, possibly preventing further attacks.

There is extensive literature on weapons of mass destruction, along with the role of first responders and ED personnel in the immediate management of associated casualties. However, there is a dearth of literature addressing the forensic aspects of a mass disaster stemming from an act of terrorism.

A team approach is vital for a timely and effective response to any of the scenarios described in this article. The earliest reports from a scene and accurate communication with the ED regarding an incident will set the stage for determining the level of threat to individuals, the community, and the hospital. Preliminary information from credible sources will also determine whether a limited or full-scale response to individual or multiple casualties will be required. ED leadership will quickly determine the required response pattern and direct the procedures for receiving and managing casualties.

Emergency personnel are generally prepared to handle most contingencies, and often thrive on the unexpected, the challenging, and the unusual incidents they encounter. As a result, they are ideally suited to assume the additional responsibilities associated with managing forensic evidence. Sharp intuitive skills, a sense of "suspiciousness" or wariness, and an intuitive nature to adapt promptly to changing circumstances are typical traits of emergency personnel. These traits enable ED personnel to effectively cope with even the most challenging events, including mass disasters or acts of terrorism

RECEPTION AND TRIAGE

When ambulatory patients arrive without advance notice, personnel must be keenly aware of how their actions and decisions in triage will impact the "big picture" of an effective response to terrorism, minimizing both environmental and human risks. Triage nurses, with their unique skills and insights, are ideally suited to recognize early signs and symptoms of exposures to chemical, radiological, or biological agents, mostly because of a heightened "suspiciousness factor." They can quickly assess and assign the patient appropriately for further care while keeping evidence collection and preservation activities at a priority.1

ENVIRONMENTAL AND PERSONNEL SAFETY

When a casualty arrives who may be suspected to be contaminated with a chemical, biological, or other hazardous substance associated with a terrorist act, immediate steps must be taken to protect the ED environment, other patients, and personnel. Although many patients will have had initial field decontamination, some individuals will not have had clothing removed or taken any other initial procedures for removing harmful agents. The collection and containment of a victim's clothing is not only an important step in decontamination, it is a first step in the evidentiary process also.

In mass disasters, those with minor injuries or with unfounded concerns of exposure or injury ("worried well") may descend upon a busy ED, often having driven themselves. The problem of these people now being exposed to those who are actually contaminated is increased exponentially. Further, even if this volume of victims can be managed, these same people will return to their potentially contaminated vehicles. It is absolutely vital that hospital security maintain control of the entry points to the facility grounds and protect the hospital from unwanted incursions. Triage efforts should begin at the entrance to the parking lot, including utilizations of a plan/flowchart, decontamination plan, and treatment admission scheme for all levels of triage.2

HAZARDOUS MATERIALS

In recent years, there has been an increase in the number and types of hazardous materials (HAZMAT) that can pose threats for hospital personnel who are not adequately equipped to handle contaminated victims and care for them. Although the prehospital personnel (eg, fire, HAZMAT, and emergency medical services [EMS]) may have accomplished field decontamination procedures, victims still require special handling when they arrive at the emergency facility. Since the fall of 2001 and in the aftermath of the anthrax-tainted letters sent to Congress and the news media, most large-scale trauma centers have access to specially trained HAZMAT personnel and have a definitive response plan in place for various scenarios.

There are federal regulations that mandate personal protective clothing and equipment (PPE) to shield or isolate individuals from the chemical, physical, and biological hazards that may be encountered at a hazardous waste site or at an incident involving HAZMAT. Occupational Safety and Health Act (OSHA) standards outline training requirements (40 hours of initial training and at least 3 days of initial field experience) for employees at uncontrolled hazardous waste operations. All hazardous waste site operators must develop a safety and health program and provide for emergency responses. These standards are also designed to provide additional protection for those who respond to HAZMAT incidents, such as firefighters, police officers, and EMS personnel. OSHA's directive, as it applies to emergency medical personnel, states, "Training shall be based on the duties and functions to be performed by each responder of an emergency response organization."3 This, of course, includes ED personnel, who continue the care of a victim of a hazardous material exposure.

The broad range of agents used as bioterrorism weapons (bacteria, viruses, and toxins of microbial, plant, or animal origin) mandates effective respiratory protection for staff and patients. Characteristics of these agents include the following: (a) the ability to disperse in aerosols of 1 to 5 mcg particle size, which can penetrate the distal bronchioles; (b) the ability to deliver these agents by a simple technology; (c) the feasibility of large populations getting infected by these agents, if delivered upwind from a target; and (d) the ability of the agents to spread infection, disease, panic, and fear.4

No combination of protective equipment and clothing can protect an individual against all hazards. There are specific types of protection that are recommended for protection when dealing with a known or unknown substance. Personnel must receive in-depth training in regard to using any PPE.

RESPIRATORY PROTECTION

There are 2 types of respirators used for HAZMAT: (1) air-purifying respirators and (2) air-supplying respirators, which include self-contained breathing apparatus (SCBA) and supplied air respirators (SAR).

Air-purifying respirators

An air-purifying respirator (APR) depends on ambient air purified through a filtering element before inhalation. The 3 types of APRs utilized by emergency personnel are chemical cartridges or canisters, disposables, and powered-air units. One advantage of the APR system is that it permits the wearer considerable mobility. Since APRs only filter the air, the ambient concentration of oxygen must be sufficient (>19.5%) for the user. The most commonly used APR is the cartridge or canister units that purify inspired air by chemical reaction, filtration, adsorption, or absorption. Disposable APRs are used for particulates, such as asbestos. Some may be used with other contaminants. These respirators often are half-masks that cover the face from nose to chin, but do not provide any eye protection. This type of APR depends on a filter to trap particulates. Filters may also be used in combination with cartridges and canisters to provide an individual with increased protection from particulates.

Air-supplying respirators

Air-supplying respirators (ASRs) are available in 2 basic designs: the SCBA, which has its own air supply, and the supplied-air respirator (SAR), which depends on a distant source for the air supply. The self-contained apparatus has a face mask connected to a source of compressed air for breathing, which is then exhaled into the atmosphere. There are also closed units that rely on a "rebreather" mask. The most popular SCBA is an open-circuit, positive-pressure unit in which the air is supplied from a positive-pressure cylinder. In contrast with the negative-pressure unit, there is a higher air pressure maintained within the mask, which affords maximum protection against airborne contaminants, that is, any leakage forces the contaminant out. (With a negative-pressure-type apparatus, contaminants may enter a poorly sealed facemask.) Supplied-air respirators are connected to an air source outside the contaminated area. These are used only at hazardous waste sites, where an individual may need to work for a long period of time around a potentially dangerous substance.

Personnel must be fit-tested for use of all respirators. A fit-test is usually conducted on a yearly basis, and is performed using a substance such as amyl acetate (banana oil) and irritating fumes to test the adequacy of the seal of the wearer's APR device.

CHEMICAL-PROTECTIVE CLOTHING

The intent of chemical-protective clothing (CPC) is to prevent the individual from coming into direct contact with a chemical contaminant. No CPC will provide protection against all substances, so emergency personnel must know the capabilities and limitations of the garments provided for their use. Furthermore, they must receive specific information on how to don and remove the various items, that is suit, gloves, mask, shoe covers, or headgear, to ensure that accidental contamination does not occur during these maneuvers.

The level of protection required to protect an individual against contact with known or anticipated toxic chemicals has been divided into 4 categories:

Level A: Highest level of respiratory, skin, and eye protection is needed.

Level B: Highest level of respiratory protection is needed, but a lesser level of skin protection is required.

Level C: Used when air purifying is required.

Level D: Not used for situations in which there is any risk to respiratory tract or skin; provides minimal protection against skin hazards and no protection against respiratory hazards.

The level of protection required is determined by the type of hazardous substance, its toxicity, and the concentration of the substance in the ambient air. Another factor involves the potential for exposure to this substance from the air, splashes of liquids, or other direct contact with materials that may occur during work. Emergency personnel may use CPC gear that is typical for Level D protection and occasionally may use certain items associated with Level C protection.

PATIENT DECONTAMINATION

The goal of decontamination in the field is to reduce risks for the victim and to minimize any potential contamination of healthcare providers (or the environment) involved in subsequent treatment of the victim.

When a hospital is notified about a potential HAZMAT incident, it is vital to obtain as much information as possible. Information that will aid in initiating appropriate actions includes5:

* Type and nature of incident

* Caller's telephone number

* Number of patients

* Signs/symptoms being experienced by the patient

* Nature of injuries

* Name of chemical(s) involved

* The preliminary treatment given

* Extent of patient decontamination in the field

* Estimated time of arrival

After the above information is received, a resource center (see Information Sources) should be contacted for further directives. When calling a resource center, be able to provide the name of the chemical substance and its physical state (ie, gas, liquid, or solid), the type and length of exposure, the decontamination or other interventions (eg, antidotes) already accomplished, and current status of the victims. They will provide further information regarding the substance and supply guidelines for additional decontamination along with personal protection equipment requirements. Unfortunately, in true terrorism events, the identification of the causative agent will likely not be positively known. Unlike an environmental catastrophe, for example, a leaking rail car containing chlorine, the terrorist weapon will not have any markings or information regarding the identification of the material that has been released. Furthermore, the field testing instruments available to first responders vary from jurisdiction to jurisdiction and have limited capabilities, especially with substances containing impurities. Therefore, ED personnel should always prepare for the worst-case scenario when planning for the receipt of contaminated victims.

Emergency medical personnel should be notified of any special approach or entrance and be advised not to bring the patient into the ED until the contamination of the patient has been assessed and accepted by the ED staff. Emergency personnel should remember that victims contaminated by HAZMAT may arrive by other than regular EMS channels and may not have had any field decontamination. These individuals must be confined and not be permitted to enter until a determination of risk has been made by qualified HAZMAT personnel or the emergency physician after consultation regarding the type and amount of contamination. In unknown incidents, full protective gear should be used until the risks to personnel and the department can be ascertained. The HAZMAT guidelines for ED preparation are annotated in Tables 1 and 2 (see Information Sources, reference 5, pp 44-46).

Table 1. Decontamination area preparation

Table 2. Decontamination of patient

Decontamination team preparation

Those individuals participating in the decontamination team must be properly protected with the level of protection recommended for the substance(s) involved (see Table 3). This is usually determined by consulting with one of the reference resources (see Suggested Resources). Wide tape (2 in) should be placed on the back of the protective suit for easy identification and to assist in communication (see Suggested Resources).

Table 3. Categories of chemical agents

All emergency personnel should assume that casualties from HAZMAT incidents will need decontamination. All clothing should be removed from the victim (if it was not previously removed at the scene) since getting rid of clothing will substantially reduce the risk of contamination to the patient, personnel, and the environment. Contaminated clothing must be double bagged in impermeable receptacles, sealed, and labeled with all pertinent identification information. Members of the decontamination team should retrieve the patients and remove them directly to the decontamination area using a route as prescribed in the facility's disaster plan. As in all emergencies, priority should be given to basic life support and simultaneous reduction of contamination. When these basics have been addressed, attention may be given to other assessments and interventions.

EVIDENCE RECOGNITION AND MANAGEMENT

Treatment ALWAYS precludes the sole focus of evidence gathering but it is crucial to remember that all victims of a terrorist attack must be viewed as potential "pieces of evidence" or as crime scenes in themselves. It is not unrealistic for the suicide bomber himself or herself to arrive at the emergency department. Careful documentation will help to distinguish whether the wound was incurred "accidentally" or self-inflicted.

It is unlikely, but surely possible, that a device may not have completely functioned or may have malfunctioned or failed. Or, as in the case of the "Collar Bomb," in Erie, Pa, the victim/patient may be locked into a live device. In these unusual cases, it may be prudent for those providing treatment to do so with the aid of a trained bomb technician and to provide care in a safe location outside of the hospital. In addition, care must be given to the components of an explosive or incendiary device before treatment is initiated. For example, treatment personnel would not want to irrigate with normal saline a wound containing phosphorus since the water would react with the phosphorus and make the wound potentially worse and injure the individual providing the treatment. Also, during any irrigation procedure, place a container under the injury or recapture the irrigation fluid, as microscopic bits of evidence may be later identified in this collection. Be aware of bomb residue and take care to swab the area or areas before cleansing and keeping each swab separate from the other. Any bodily fluid may contain physical evidence of some type that may be the missing link with identifying a perpetrator, a modus operandi, or specific device. These may include sputum, vomitus, chest tube drainage, bronchial washings, blood, urine, and fecal material. If possible, have the victim stand or lie on a clean sheet on the floor or around the victim before removing clothing. Small bits of debris that may be evidence of specific parts of explosive devices will be easily preserved when folded and properly packaged. Precise documentation of wounds and injuries, including photography, will assist investigators in determining the direction and force of the blast. Documentation of comments and excited utterances are critically important as well.

While any point of entry for a patient into a hospital or medical facility provides a variety of potential medicolegal scenarios, it is the ED with its potpourri of human tragedy that is the greatest minefield of forensic challenges. The triage nurse is most often the first licensed clinician to see the patient. The nurse is also the one most likely to observe interactions and nonverbal communication between the patient and significant others. It is this ED nurse who will most likely be the first to face a victim of a biological or chemical agent, be it an isolated incident or the first of many to come.

Most emergency personnel never consider the forensic implications of their particular practice area until they are faced with a situation. As forensic science gains increasing attention within healthcare, all personnel will find that they must not only keep up with those aspects that apply to delivering patient care, but also evidence collection, so that they do not unwittingly find themselves liable to be held for destruction of evidence or inadequate care or documentation.7^(p409) This is applicable to the EDs' role in responding to an attack and being able to function as team players in a large-scale response or investigation while caring for individuals who have been exposed or injured.

CONFIDENTIALITY ISSUES

With regards to the dilemmas regarding patient privacy and confidentiality that may arise in these situations, personnel should focus on providing treatment and preserving evidence, and avoid being overly concerned with these matters. In true terrorist attacks, the bombing in Oklahoma and others, all of the medical records of victims will almost certainly become part of the overall criminal investigation. Therefore, all medical personnel should take the time and effort to collect evidence and document their findings in the victim's medical records. It is likely that the victim's medical records will be the clinician's only notes of the disaster and he or she will be called to testify at subsequent legal proceedings. In addition, the treating clinician will likely be called upon to collect biological specimens that will be analyzed forensically as well as clinically. Preplanning between the legal department and ED, prior to an event, can prevent the loss of evidence and will facilitate patient treatment and evidence collection. Protocols can be put in place that will allow for patient treatment and evidence collection. Those who will review the medical records of these types of cases at a later time will certainly have the appropriate authority to do so. The focus of all healthcare personnel in situations like these should be treatment, documentation, and preservation of evidence. No clinician wants a reputation of providing poor care, much less being charged with obstructing an investigation, all of which will be highlighted should this become a high-profile situation.

Most healthcare professionals realize that failure to act is tantamount to acting negligently. Individuals with specialized forensic education and training are presumed to possess greater knowledge and a unique skill set. They may actually be held to an even higher standard when their assessment, treatment, and referral skills do not adequately protect the patient; no nurse is "off the hook." All nurses should be aware that they may be subject to a criminal charge of obstruction of justice if they destroy evidence.7^(p409) Given the heightened state of anxiety of the public following a terrorist event, it is unlikely that medical personnel will be forgiven by the public if they do not correctly document and collect evidence from victims. Merely saying they were too busy with patient treatment may not suffice, especially if their error or destruction of a piece of evidence leads to an acquittal. Clinicians will be expected to balance their response to victims, collecting evidence whenever it is safe to do so and preserving such evidence for further testing. History has shown that poor documentation and evidence preservation in high-profile cases often leads to conspiracy theories. In the John F. Kennedy assassination, poor documentation of the president's wounds in the ED has lead to any number of theories about his death. If the treating physician had taken the time to properly document the president's wounds, perhaps less theories would exist for this tragic event.

WEAPONS OF MASS DESTRUCTION AND BIOTERRORISM

The 1999 Emergency Response to Terrorism Self-Study Manual published by the Federal Emergency Management Agency (FEMA) for training fire, medical, and HAZMAT first responders lists 5 categories of terrorist incidents and uses the acronym B-NICE as a simple way to remember them (biological, nuclear, incendiary, chemical, and explosive). Four routes of entry are also listed, including inhalation, absorption, ingestion, and injection.8 For purposes of this article, explosive, chemical, radiological, and biological agents will be discussed.

BOMBS AND OTHER EXPLOSIVE DEVICES

Explosions are caused when an explosive device is detonated or an explosive is accidentally ignited. Explosives are substances that have a shattering or brisant effect when they explode. Such an effect is utilized particularly for blasting in quarrying, mining, and tunneling, where large masses of solid material have to be broken up quickly and cheaply.9^(p4.183) There are 2 categories of explosives: the first comprises any substance or article that includes a device designed to function by explosion, and the second is any substance or article that by chemical reaction within itself can function in a similar manner even if not designed to function by explosion.10^(p20)

The injuries from explosions are mainly due to 4 factors: blast or shock wave, flame or hot gases, flying missiles, and anoxia. In a blast, the shock wave produced spreads concentrically from the explosion site, at the speed of sound, and anything in the immediate vicinity is completely obliterated. Thus, a victim who does not survive will not likely be transported to the ER. However, if the explosion occurs at a greater distance, it may blow the victim against the wall or toss him through the air causing blunt force injuries. This individual may survive and indeed end up in the emergency department.

The parts of the body usually damaged by blast waves are the hollow organs that contain gas or air, such as lungs, bowels, and eardrums, as well as those most fragile and easily displacable such as the brain and abdominal viscera. Burns produced by explosion are usually very extensive and are accompanied by blackening and tattooing due to the unexploded particles that have been driven into the skin. Abrasions, bruises, lacerations, and various ragged perforations may result from flying debris. The parts of the body most affected by flying fragments may indicate the position of detonation. Letter bombs, for example, cause the most damage to the hands, face, and front of body. Finally, depending on the contents of the explosive, various gases may be liberated and their inhalation may result in poisoning.9^(p4.184)

Forensic processes and actions

Ideally, there should always be at least one person on duty and on every trauma team focused on the forensic evidence and keeping track of activities as it pertains to evidence collection and preservation. It is not always possible in stressful life-saving situations for every person on the team to keep track of every detail.

Radiographs should be taken of all the victims before any treatment since it is possible that unexploded ordinance may be inside or on the person. Use caution. Keep the victim away from electrical sources, where leakage current, shock, or friction might be produced, permitting the ignition or triggering of some explosive device. Defibrillators, of course, would pose a significant risk if they were employed in such instances.

Documentation should be precise and thorough. Use photography and body diagrams to describe and identify the locations of wounds and injuries. All surgically removed metals or other material need to be saved and labeled. All clothing should be packaged carefully and labeled. Clinical samples should be segregated after analysis.

If feasible, the victim should be interviewed as soon as possible after being stabilized. Keep victims away form each other so that independent knowledge may be gleaned from each interview.

As with the evidence in other types of medicolegal cases, the evidence is labeled and sealed, and the chain of custody is maintained until turned over to appropriate authorities. The physical evidence recovered in an ED room is as valuable as the evidence found at the site of the explosion. Key questions investigators are trying to answer include the following10^(p304):

* Materials used to make the explosive device

* Where the suspect obtained the materials to construct the device

* The level of skill of the suspect

* The target of the bomb

* Where the bomb was made

* Who made the bomb and who placed it

* Where the bomb was placed

* How the bomb was detonated

DIRTY BOMBS AND RADIOLOGICAL WEAPONS

A radioactive "dirty bomb" involves exploding a conventional bomb that not only kills victims in the immediate vicinity but also spreads radioactive material that is highly toxic to humans and can cause mass deaths, radioactive sickness, and injury. Essentially, radiological dispersion devices are conventional bombs wrapped in radioactive waste, which can readily be found in hospitals and industrial plants. Unfortunately, radioactive waste materials are much more widely available than weapons-grade materials and are kept in conditions that are not highly secure. Dirty bombs can be miniature devices or as big as truck bombs.11^(p24)

Medicolegal considerations and response

When initially approaching the scene of an event involving a dirty bomb, rescue personnel should be cautious and be aware of HAZMAT. A command post from which all activity will be directed, should be set up at a safe distance (at least 150 ft) upwind and uphill of the site to prevent contamination of the clean area by wind. Personnel will utilize personal protective gear (PPG) and equipment. A control line should be established near the ambulance, with personnel remaining within the control (contaminated) area.12 Hospitals and other authorities should be notified as soon as possible.

Victims with life threatening injuries should be immediately evacuated and considered contaminated. Radioactive contamination is never immediately life-threatening, and decontamination can occur once life-threatening injuries are treated.13 Once life-threatening injuries have been stabilized, the radiation exposure should be measured by a Geiger counter, if available, at the control line. Once contamination is confirmed, clothing is removed and preserved as evidence, and the patient is transferred to the clean side and transported to the emergency department. Wounds should be exposed and covered with sterile dressings.14

Ideally, the ED would have to be notified and the hospital's Radiological Response Plan initiated. Ropes and signs may be utilized to control the ER area by specifying routes and identifying clean and contaminated areas. Entrance and exit areas should be monitored by security to prevent the spread of contamination as well as unauthorized access.12 Emergency staff should be wearing PPG, and the gloves are taped down at all seams while cuffs are covered with a second pair of gloves so that they can be easily removed.14

Once the patient arrives, attention must be given to decontaminating wounds. Each wound should be exposed, draped, and flushed with copious amounts of sterile saline or water. Once the wound is considered clean, a waterproof dressing should be applied. Then, the rest of the body may be decontaminated by washing with mild soap and water.14

At some point in the treatment process, ideally immediately after being stabilized, the patient should be interviewed and a thorough history obtained to include the patient's location relative to the center of the blast. This information will assist in determining the approximate amount of pressure the patient was exposed to. A thorough physical examination is required, with special attention to the lungs, abdomen, and tympanic membranes. The medicolegal implications of injured tympanic membranes indicate that a high-pressure wave was present. This documentation of position and injury will corroborate other findings by investigators at the scene.

Blood, urine, feces, and any other samples taken initially should be retained by pathologists or public health officials, if necessary. Nasal specimens may also be helpful, especially in cases were the radiation source is a fine powder (cesium). Each sample is marked with all identifying data, time the sample was collected, location, collector's names, and size. Meticulous documentation for forensic and long-term follow-up must be maintained during mass casualty events surrounding a dirty bomb. Investigations and litigations against responsible persons is sure to follow, and accurate medical documentation is critical in corroborating injury and radiation exposure. Documentation is extremely difficult during the chaos of initial response and management but it must be completed and is another reason to have a dedicated forensic clinician focused on these aspects of victim management.12

All shrapnel recovered from wounds should be collected and appropriate chain of custody documentation should be maintained until the items are transferred to the FBI or other law enforcement personnel. The shrapnel and other components of the device are extremely important to the subsequent law enforcement investigation. For example, in the Pan Am 103 bombing, a piece of a circuit board, the size of a quarter, became a pivotal piece of evidence that ultimately lead to the identification and conviction of the 2 Libyans responsible for the blast. In addition to any of the components of the improvised explosive device (IED), consideration should be given to the collection of nasal swabs, both as clinical as well as forensic specimens. Nasal specimens will be useful to confirm exposure to the nuclear material and may be suggestive of internal exposure. In addition, nasal swabs will contain the causative isotope and will be examined forensically to possibility determine the origin of the nuclear material. Furthermore, consideration should be given to utilizing biodosimetric techniques to determine the extent of victims' exposure. Radiation dose determinations are conducted by assessing the extent of chromosomal aberrations (dicenteric chromosomes) in peripheral blood lymphocytes isolated by whole blood samples.15

CHEMICAL WARFARE AGENTS

Chemical agents that might be used by terrorists range from warfare agents to toxic chemicals commonly used in industry. Criteria for determining priority chemical agents include

- chemical agents already known to be used as weaponry;

- availability of chemical agents to potential terrorists;

- chemical agents likely to cause major morbidity or mortality;

- potential of agents for causing public panic and social disruption; and

- agents that require special action for public health preparedness.

Medicolegal considerations and response

Again, the response includes setting up appropriate areas to decontaminate victims of chemical agent exposure. The literature highlights different methods of organization for this activity from emergency and fire department response teams around the country. One of the more ideal plans includes setting up special chemically coated nylon structures outside of the ED. Each unit has 3 corridors to accommodate females, males, and the nonambulatory. The victims enter in an assembly-line fashion and remove their clothing, placing these and all personal belongings into a plastic bag. An attendant writes the surnames on the bag and discards it into a suitable evidence recepticle. This is said to remove 80% to 90% of the contaminants. Then victims would enter the second tent and which will provide a shower and mild soap. Each person finally reaches the last tent and is provided with paper clothing that can be worn en route to the hospital. Belongings are returned once these are declared safe or are incinerated and vaporized.16 All of the victims' clothings potentially contain the chemical agent. As such, the victim's clothing should be considered evidence. Most often, the victim's clothing will be left at the scene and packaged accordingly. In some cases, the victims may make their way to the ED before being decontaminated. In these cases, any clothing removed prior to decontamination should be preserved in some fashion. Even if the ED doesn't have the perfect container for the clothing, it should be saved and contact made with the FBI or local law enforcement for guidelines on how to package the clothing. In the case of volatile chemical agents, the clothing should be placed in plastic bags or clean paint cans. Large amounts of clothing from a mass casualty event should be placed in plastic bags and the bags placed in clean 55-gallon drums. As for the patient victim, prior planning with local health departments should have resulted in protocols regarding the proper collection and preservation of biological specimens that will be tested forensically and clinically. If protocols are not in place, ED personnel should contact their designated Poison Control Center for guidance on the correct specimens to collect and the appropriate tubes for collection. Even if the best specimens have not been collected at the optimum time, all specimens collected from the patient-victim should be retained as evidence. Any specimen from the victim is better than no specimen.

Bioterrorism collection kits are currently being proposed for the collection of samples from victims of a chemical attack. At the present time, it is being suggested that 3 lavender top tube blood specimens, one gray or green top tube blood specimen, and a urine specimen be collected utilizing forensic chain of custody protocols. Secondary specimens or nonforensic samples may be collected as part of the clinical evaluation of the patient (D. Barden, oral communication, 2005). After clinical testing of the secondary specimens these specimens, should be maintained and the custody transferred to law enforcement.

BIOTERRORISM

Bioterrorism has no boundaries and can happen anywhere at any time.17 Category A biological agents are those the "U.S. public health system and primary healthcare providers must be prepared to address."18 They are considered threats to national security, are highly transmittable, and have high mortality rates.18 These agents include anthrax, botulism, smallpox, tularemia, viral hemorrhagic fever, and plague (Appendix 1). The Centers for Disease Control and Prevention has ranked possible bioterrorism organisms into 3 categories on the basis of their abilities to

* be easily disseminated or transmitted person-to-person;

* cause a high mortality and present major public health impact;

* cause panic and social disruption; and

* require special action of public health preparedness.18

"Bioterrorism is 1% bio and 99% terrorism. Such incidents are designed to overwhelm health resources, not with the casualties, but with the many who are well, but worried. Responders who understand the organisms that may be involved and treat the scene in a professional manner will reassure the public while protecting themselves."19 With recent legislation granting hospitals across the country federal monies for bioterrorism preparedness, it is painfully obvious that healthcare facilities are indeed a target for terrorists with weapons of mass destruction. In the very least, they will be called upon to harbor and treat masses of infected individuals.20 Hospitals everywhere continue to prepare for such an event but it is really left to the individual facility as to the details of those preparations. Two of the very important details not to be overlooked are again the medicolegal aspects of each case and the impact the clinician may have on the overall picture.

Realistically, most acts of bioterrorism will likely be covert as opposed to being an announced threat.19 The first indications of such an incident will appear in the emergency department as the ill start to come in. These individuals will not all come in at the same time or on the same shift or even see the same clinician. Specimen collection in these cases will likely occur before the terrorism event is realized. However, after an event has occurred, strict forensic guidelines should be followed for documenting any specimens collected from potential victims. Many states have implemented protocols for collecting such specimens and have placed collection kits akin to sexual assault evidence kits in EDs. The State of Connecticut Bioterrorism Collection Kit, which is located in every ED, consists of the following: plastic touch prep slides, a viral culturette, an envelope with a pair of plastic scissors for the collection of clothing (for ricin [Appendix 2]), a red-top blood tube, and a scalpel for the collection of a skin sample. In addition, the kit contains instructions for use and a chain of custody form. This kit was originally designed for the collection of samples from potential smallpox victims. However, additional items and instructions have been added to the kit to make it useful for most bioterrorism agents. The kit does not contain blood culture kits simply because patients that present with fevers of unknown origin will be cultured according to good medical practice norms. Any isolates of interest that are cultured in hospital laboratories in the state of Connecticut, are subsequently forwarded, utilizing forensically sound chain of custody protocols, to the State of Connecticut Department of Health Laboratory for confirmation.

SUMMARY

The forensic nature of human-caused disasters exists because the event itself is a criminal act. Forensic science can serve as a deterrent by increasing the likelihood that the terrorists will be apprehended before fully launching a successful attack.21 The ED personnel have distinct responsibilities as part of the "bigger picture" in the response toward a mass attack or disaster. It is no longer sufficient to be able to competently manage the triage and treatment of these victims. It has become vital that emergency clinicians become indoctrinated in forensic science and broaden their expertise to include the identification and management of forensic medical evidence as well as to understand that their cooperation with investigators and other authorities is crucial in identifying perpetrators and future risk factors.

With few guidelines currently available for bioterrorism preparedness, hospitals are on their own in planning new policies and implementing new procedures. They must perform an evaluation of their capacity to address both the direct and indirect effects of a bioterrorist attack.18

Hospitals in high-threat areas should focus their bioterrorism preparedness measures on information technology, disease surveillance, and equipment.18 Furthermore, emergency department personnel and other clinicians who will be called to respond must remain current in not only the appropriate treatment of victims but in the forensically related knowledge, skills, and abilities necessary to function as team players on a bigger stage.

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