Disasters from Biological and Chemical Terrorism—What Should the Individual Surgeon Do?: A Report from the Committee on Trauma

In the weeks following the September 11 disaster, we have all been asking how we can prepare for a homeland disaster response to acts of biological and/or chemical terrorism and how we as individual surgeons can get involved.

The exact answer to these questions is not yet clear. Increasingly, we are beginning to identify the approach that we should each take in our communities. Following are some concepts and recommendations to guide each Fellow as we proceed toward developing a definitive answer to these questions.

An organized response

A trauma and EMS system is designed to be an organized response to injury. As such, it has many of the elements needed for a disaster response, including identification of injury, transport of the injured, a communications network, designation of receiving facilities or hospitals, and specifics details of medical care that would be appropriate at the point of injury and at receiving hospitals.

The response required for a biological or chemical disaster may be proportionally different, but, in principle, is still an organized response to injury. Differences would include: the magnitude and types of injury, the numbers of injured, and the risk to providers of exposure and personal injury. Chemical and biological disasters may not be addressed by trauma systems planning in a local community, and a disaster response will differ from a traditional trauma/EMS system in four ways.

First, the traditional hospital-based trauma program will need to be modified to include a chemical or biological response ability. Such capability will require involvement of various different elements within the hospital in addition to the traditional trauma program.

Second, at the local/regional level, each hospital needs to be integrated with the county or state disaster plan and the government agencies that would be involved in such a plan. The details of the biological and chemical disaster plans will differ from conventional trauma/EMS disaster plans.

Third, a disaster of significant proportion may require the participation of the National Disaster Medical System (NDMS) and the military. How this system is activated and interfaced with the local/regional response should also be clear to everyone involved.

Finally, the uniqueness of biological and chemical injuries may exceed a practitioner's current knowledge, which may include deficiencies in knowledge regarding techniques of surveillance and detection, the need for specific procedures to protect prehospital and hospital providers, the signs and symptoms of disease, and treatment.

As we respond to this challenge we all must:

1. Expand our current trauma/EMS systems to respond to biochemical disasters.
2. Increase specific knowledge at an individual practitioner level.

The surgeon's role

Surgeons are natural leaders. We should lead this effort in our communities. The following are specific recommendations for surgeons to consider:

1. Within each hospital, surgeons should participate in defining and developing the internal response capabilities of their hospitals for biological and chemical injury. A guide for accomplishing this goal has been developed by the Office of Emergency Preparedness of the US Department of Health and Human Services and the American Hospital Association. This guide can be accessed at http://www.bt.cdc.gov/. The internal response system of each hospital should include procedures to increase surveillance of infectious disease in coordination with the state and local health agencies. The surgeon needs to work as or with the local hospital trauma director, the hospital director, infectious disease and critical care colleagues, toxicologists, and pharmacists to ensure that the internal response is operational. An additional resource to help with hospital disaster plan development is Chapter 20 in the American College of Surgeons' manual Resources for Optimal Care of the Injured Patient: 1999.
2. The surgeon must understand how the local trauma and EMS system and disaster plan function. They should work with the local trauma/EMS system to determine what mechanism exists and how responses need to be modified or expanded to deal with chemical and biological threats. You can identify the appropriate individuals to contact by linking to your state or local EMS agency from the National Association of Emergency Medical Directors at http://www.nasemsd.org/.
3. The surgeon should know and understand the National Disaster Medical System and how it works. This system is activated through local, state, and federal agencies. The NDMS complements local/regional resources and can mobilize them through a mutual aid agreement with other government agencies. Examples of some of the multiple resources that are available include search and rescue teams, medical response specialty teams (SPECIALTY DMAT), the National Pharmaceutical Stockpile, and evacuation capabilities offered by the Air Force. Details regarding the National Disaster Medical System can be obtained at http://www.ndms.dhhs.gov/.
4. The individual surgeon needs to expand his or her own knowledge of biologic and chemical agents by learning: (1) agents that are most likely to be used, (2) the appropriate initial injury control and risk reduction procedures, (3) what the presenting signs and symptoms are and the natural history of exposure, and (4) definitive treatment. A primary resource for didactic information is available on the CDC Web site at http://www.bt.cdc.gov/.
5. The surgeon should participate in the education of colleagues, hospital staff, and administration. He or she should partner with local public health officials to educate the public regarding the thoroughness of the local disaster response, the need for specific prevention measures, and the comprehensiveness of our national systems for disaster response and management.

Beyond participating in their local hospital and community plans, surgeons are asking how they might participate at the national or international level in either a homeland disaster or war. The American College of Surgeons Committee on Trauma will continue to provide information with regard to these opportunities as they are clarified. Currently, participation in the NDMS by joining a local DMAT team is one possibility. Further information can be accessed at http://www.ndms.dhhs.gov/.

The College will continue to use ACS NewsScope, its Web site, and the Trauma Office to provide  answers to questions regarding available resources for all Fellows.

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