Emergency Medical Services and Medical Countermeasures to CBRNe and Emerging Medical Threats
By Frank G. Rando
“And by a prudent flight and a cunning save
A life which valour could not from the grave
A better buckler I can soon regain,
But who can get another life again?”
The development of the Emergency Medical Services (EMS) started in the 1970s and today have grown into a force that is able to adequately respond to WMD/CBRNE threats, as well as public health emergencies, such as terrorist attacks and infectious disease outbreaks. Frank G. Rando looks at the evolution of the EMS and the capabilities they have today.
Medical countermeasures (MCMs) are biologicals, drugs and devices that may be used to counter the medical effects of CBRN-related and other emerging health threats. A public health emergency may ensue due to the use of CBRN agents or an emerging infectious disease, such as Ebola viral hemorrhagic fever or pandemic influenza. On the front lines are our First Responder Emergency Services, of which the most relevant to public health threats are the prehospital Emergency Medical Services (EMS).
“We should never forget that God granted us the power to reason so that we would do His work here on Earth – so that we would use science to cure disease, and heal the sick, and save lives.” (Barack Obama)
Prior to the 1970s, civilian ambulance services in many areas were merely transport services rendering only rudimentary first aid care to trauma and medical patients, with some simply being “scoop and run” operations. One would often see funeral directors doubling as ambulance drivers and attendants and hearses being used as ambulances. As the 1970s progressed, the concept of emergency medical technicians (EMTs) and advanced emergency medical technicians or paramedics capable of providing higher levels of care in the field and in transport arose with the aim of changing the tide of prehospital morbidity and mortality, stemming from the dismal statistics associated with traumatic injuries from highway accidents generated by the US Department of Transportation (USDOT) and the National Highway Traffic Safety Administration (NHTSA). The poor outcomes from out-of-hospital cardiac arrests were another reason to think outside of the proverbial box regarding developing a standard national training curriculum and upgrading ambulances to mobile intensive care units (MICUs), also referred to “mobile emergency rooms” or fire department-based paramedic rescue units, in cities such as Los Angeles, Seattle, Columbus, and New York. In addition, Emergency Medical Services Systems (EMSS) in general were created throughout the US and abroad, consisting of not only field based mobile assets, but fixed medical treatment facilities (MTFs) equipped with the latest sophisticated emergency medical, trauma, and critical care units.
These models were based on other EMS projects like Dr. James Francis Pantridge’ s “Flying Ambulance” dispatched from the Royal Victoria Hospital in Belfast, Northern Ireland and the mobile cardiac care unit responding out of New York City’s St. Vincent’s Hospital, under the medical direction of Dr. William Grace. In addition, cumulative data derived from combat medicine during the Vietnam War had then indicated that due to frontline medical care provided by trained medics and corpsmen, combined with rapid helicopter medevac assets and early surgical interventions at forward combat hospitals, the morbidity and mortality attributed to battlefield injuries were significantly lower than civilian highway death rates due to trauma incurred in motor vehicle accidents. In 1966, this resulted in a sentinel White Paper entitled Accidental Death and Disability in America: The Neglected Disease of Modern Society, which influenced much of the thought and improvements in prehospital emergency medical care over subsequent decades.
As the civilian world experienced a barrage of asymmetric threats and terrorist attacks and as novel and exotic pathogens evolved and made cross-species jumps and infected humans, this “new normal” generated a need for tactical, disaster and operational medicine, as specialty areas of emergency and prehospital medicine. To refine even further and to accommodate the medical response to WMD/CBRNE threats, counterterrorism medicine rose to meet the special needs and challenges presented by these agents of war and terrorism.
Throughout the world, military and civilian units and specialized teams have been formed to detect, diagnose, decontaminate, triage, treat and transport those exposed and affected by CBRN agents, emerging infectious diseases, and other public health emergencies, such as accidental hazardous material spills or releases. An example: at local municipal or county levels, EMTs and paramedics have cross-trained to become hazardous materials technicians and/or “tox-medics” or “haz-medics” trained in advanced clinical toxicology and antidotal therapies. Most recently, during the Ebola and COVID-19 public health emergencies, EMS personnel played a role in the care and transport of infected patients. During the COVID-19 pandemic, emergency medical personnel were given the roles of providing mass vaccine prophylaxis at a variety of fixed and mobile sites and served as clinicians at Alternate Care Sites (ACS), medical treatment facilities established in non-traditional settings during a public health crisis, often under austere conditions.
Specialized EMS units designed for mobile biocontainment are a unique asset in both military and civilian response to public health emergencies. A standard role for EMS personnel would be to administer prophylactic and therapeutic agents, such as atropine, oximes, as well as anticonvulsants for nerve agent/cholinergic toxidrome or hydroxycobalamin, the B-12 analogue that serves as an antidote for cyanide poisoning.
The current concept in patient management in CBRN events, promulgated by current military medical doctrine is to enable field medical resources to commence lifesaving interventions in a hot zone, such as the administration of a nerve agent antidotal therapy. EMS agencies could be requested to participate in hot zone operations, if tasked and trained to do so, or operate in the warm zone to conduct triage and other medical support functions in decontamination operations. Generally, though, EMS assets operate in the cold zone. EMS assets would also be providing supportive therapy, such as administration of oxygen, airway management and IV therapy, as well as ongoing assessments and monitoring of victims.
Another area for deploying EMS personnel would be in mass screenings and prophylaxis efforts involving biological agents. These EMS personnel would be located at points of dispensing/distribution or PODs. These locations would be set up by public health departments and manned for the administration of prophylactic antibiotics or vaccinations in the aftermath of a bioterrorism event or naturally occurring infectious disease outbreak. EMS agencies in the US, especially in larger municipalities designated as Metropolitan Medical Response Systema (MMRSs) or Urban Area Security Initiative/Cities Readiness Initiative metropolitan areas, are aware of the availability of Chempack resources, which are forward deployed MCMs to counter nerve agent toxicity in a domestic chemical terrorism event. The Chempacks are a component of the Strategic National Stockpile (SNS), which contains a variety of deployable MCMs. All EMS personnel need to be aware of SNS assets and how they are requested and deployed.
In the last several years, we have witnessed assassinations and attempted assassinations utilizing among the most toxic formulations of military grade nerve agents, such as VX and a Russian produced Novichok analogue, as well as the intentional poisoning of a Russian dissident, journalist and former FSB operative with the radionuclide, Polonium-210. EMS assets are essential in the planning and operational phases of public health emergencies, including terrorist attacks and infectious disease outbreaks. EMS is the intersection between public safety and public health. As such, EMS personnel may also utilize rapid biological assays to confirm infection, chemical monitoring devices and assays to detect or diagnose chemical toxicants or validate exposures and utilize MCMS specific for radiological and nuclear events. In CBRN events, EMS assets are of critical importance so that others may live.
About the Author:
Mr. Frank G. Rando currently serves as an allied health programs educator/lead instructor and healthcare emergency preparedness/medical readiness/public health preparedness and tactical, operational – disaster medicine and homeland security subject matter expert, educator, instructor, and curriculum designer. He has served in instructional, guest speaker and consultative roles for DHS-FEMA, various components of the National Domestic Preparedness Consortium, US Department of Defense, industry, academia, health, safety and regulatory entities, emergency services organizations and healthcare.
* Heading Picture: FDNY “HAZ-TAC” Rescue Medics Ambulance – Haz-Tac paramedics are trained to respond to operationally challenging scenes including CBRN/HAZMAT incidents, © Instagram/Michael W Kuehn