Statement on Unconventional Acts of Civilian Terrorism: A Report from the Board of Governors

Recent events have increased the public's sensitivity to acts of civilian terrorism. Terrorist acts with conventional explosive devices can result in mass casualties secondary to kinetic and thermal energy that require surgeons for their treatment. Unconventional Acts of Civilian Terrorism (ACTs) have the potential to kill and injure hundreds of thousands of individuals while destroying the health care infrastructure necessary for care of survivors. As a result, they require a new level of preparedness. By virtue of their training in trauma and critical care, surgeons will play a major role in our health care community's response to any unconventional ACTs.

Three types of ACTs

There are three major categories of unconventional ACTs:

1. Nuclear/Radiation Events: Radiation terrorism can be activated through three major routes. Nuclear detonation is one. Radioactive material placed into a conventional explosive is a second. A third would be direct efforts to disseminate radioactive contamination through food, water, or direct environmental spread.

In a nuclear detonation, injuries sustained outside of the lethal perimeter of the explosion due to kinetic and thermal energy will require treatment; such injuries will also be characterized by severe acute radiation exposure. Irradiation injury does not make the patient radioactive, but surface radioactive contamination requires decontamination through removal of all clothing and tepid bathing of the skin surfaces, preferably before the patients are transported to hospital facilities for management of physical injuries. Patients with minimal or no injury should be transported to designated (by the community disaster plan) non-health care facilities (for example, gymnasiums, arenas, convention centers, and so on) where showering or temporary decontamination activities can be conducted. The use of private transportation will result in patients arriving at health care facilities prior to decontamination, thus posing potential risks to health care workers. Injured patients will require decontamination at the health care facility. Uninjured or minimally injured patients should be triaged to the non-hospital decontamination site.

2. Chemical Events: Typical chemicals which potentially could be used in ACTs include cyanide, nerve gases (for example, sarin), pulmonary toxicants (for example, phosgene), vesicants (nitrogen mustard), and others. Cyanide and nerve gas exposures require prompt recognition and specific antidote administration. Pulmonary toxicants require ventilator supportive care for severe lung inflammation. Vesicants require rapid decontamination and management of the chemical burns. All chemical agents preferably require in-the-field decontamination to protect against continued patient exposure and to protect health care providers from exposure. There is the potential that chemical agents will be used with conventional explosives, and exposure may not be appreciated until chemical injuries, independent of physical trauma from the primary explosion, are recognized.

3. Biological Events: Biological ACTs include bacteria, viruses, and biological products. Anthrax, Brucellosis, Yersinia pestis (plague), and cholera are the more commonly identified potential bacteria in unconventional ACTs. Smallpox and numerous hemorrhagic fever viruses are the viral strains of interest. Botulinum toxin, enterotoxins, ricin, and mycotoxins are biological products recognized as agents of bioterrorism. Other agents will likely be identified with time. Airborne delivery of biological ACTs may be used, or the could be delivered via food and/or water. Some biological ACTs are rapidly fatal infections (for example, untreated and inhalation anthrax) while others are severely incapacitating. All ACTs have a delay from the time of exposure until clinical symptoms—such as flu-like syndromes—occur. Thus, extensive exposure could occur before the primary event is appreciated. Airborne biological ACTs will likely be delivered with conventional explosives.

Recommended actions

The threats posed by unconventional ACTs require a new level of disaster preparedness, and a new level of knowledge by surgeons who care for patients who are casualties as a result of these events. To meet the challenge of these new issues, the following recommendations are being made:

• Fellows of the American College of Surgeons should actively participate in the disaster-planning processes in their local communities and geographic region. Old disaster plans that address bygone conventional threats do not apply to unconventional ACTs. The threats and consequences of this new era require that surgeons be agents for change in community disaster awareness and planning.
• Fellows of the College will require extensive education and training in the pathogenesis, diagnosis, prevention, and treatment of the likely agents of unconventional ACTs. Education in the development of disaster plans in this new era is also required. The College will take a leadership role and will disseminate educational information through ACS NewsScope, the Bulletin of the American College of Surgeons, the Journal of the American College of Surgeons, state chapter meetings, and the Spring Meeting and the Clinical Congress in the fall. A plan for educational activities about unconventional ACTs will be jointly coordinated through the Governors' Committee on Bloodborne Infection and Environmental Risk, the Committee on Trauma, the Division of Education, and other pertinent groups within the College.
• Fellows of the College should be leaders in community education of other health care providers and of the nonmedical community through structured programs created through the College. Such education can be facilitated with the development of audiovisual materials, manuals, and an organizational structure that will be a supplement to existing resuscitation courses (for example, the Advanced Trauma Life Support course). The community that is best prepared may best minimize the consequences of a terrorist event. The community with an open and clearly present public effort to prepare and deal with this problem may be less attractive to those who perpetrate ACTs.
• The College should accept a policy of universal standards for the response to all potential terrorist events. The true nature of any explosion event may not be defined until well after it has occurred. First responders to such events should have appropriate protective gowns, NP-95 Respirator masks, and so on. In-the-field decontamination is desirable before injured patients are evacuated to health care facilities. Noninjured, or minimally injured, individuals should be evacuated to designated non-health care facilities for the decontamination process. Individuals who are privately conveyed to the health care facility should be triaged in terms of the severity of their injuries, and either decontaminated at the health care facility or sent to the decontamination facility.
• The College should rapidly develop formal relationships with federal, state, and private disaster planning and response units to facilitate education, training, and research.

Unconventional Civilian Disasters: What the Surgeon Should Know

Resources on Bioterrorism and Unconventional Civilian Disasters

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by the American College of Surgeons, Chicago, IL 60611-3211