New York, Madrid, London: What City Is Next?

Like 11 September 2001, the dates 11 March 2004 and 7 July 2005 will be forever remembered by those who lived through the terrorist attacks launched against the defenseless citizens of three of the Western world’s greatest cities. These and other large-scale attacks, which affect all democracies everywhere, pose a special set of problems for those charged with the responsibility of planning for an appropriate response.

The essence of most if not quite all such attacks is their unpredictability. All military professionals know that the optimum field of battle is at a time and place chosen by their own commanders. In the global war on terrorism it is recognized that the opposition – al Qaeda and other international terrorists – usually will have the advantage of picking the time and place of the initial assault. But the emergency-management community of the nation attacked can and should, with proper planning, choose how, when, and where to respond.

Last week’s terrorist attacks in London, coming without warning as they did, raise a number of questions, some new and some old. Among the more important issues now being addressed by U.S. and allied contingency planners are how to prepare for and respond to future attacks and how to set and, as necessary, adjust the graduated alert levels needed under the current system.

The first and possibly most difficult question the contingency planners have to answer is, “What is an acceptable level of day-to-day risk?” The United States is a risk-adverse society, and the historical American tendency has been to look to legislation, and to government bureaucracies, for solutions to almost any problem – with litigation available as a fallback. Current laws in most if not all U.S. jurisdictions, for example, require the use of a helmet when operating a motorcycle – or even a bicycle or a scooter. The nation’s enforcement structures are built around such laws, but usually allow for litigation when there are extenuating or mitigating circumstances – or when the law itself does not cover all possible contingencies.

Risk-Free Lives; Rush-Hour Complications

Unfortunately, by their very nature terrorists do not worry about the legality of their actions. Once the decision has been made to make a bomb and bring it onto a train or other public conveyance all of the various safeguards and small rules that have been implemented to minimize risk in the day-to-day lives of average citizens make no difference.

The traditional desire to live risk-free has to be weighed against the compressed, non-stop, high-speed life style most Americans follow today. At first glance the possibility of having to spend a certain amount of additional time waiting to get on a plane or train (or bus or subway, as in London) does not seem to be a major problem – perhaps because, in the case of planes, most Americans fly only occasionally. But if there were an additional half hour added to every train or bus ride a two-hour round-trip commute to and from work would become a three-hour round trip – and at rush hour an additional half-hour delay might easily balloon into an hour or more, pushing the total commute past the four-hour mark.

The London bombings apparently occurred in the absence of an increased level of background “chatter.” And that raises another question: With little or no intelligence from the ground (or from cyberspace), and with no overt threat, how can authorities develop, in advance, a reasonable response plan that might be implemented when an unexpected disaster occurs suddenly and without warning?

Insofar as alert levels are concerned, perhaps the first question to ask is, “What is an appropriate and acceptable baseline level to start from?” It seems obvious that a rise in the national threat level should trigger at least some action that raises the alert level above the original baseline. An increase in the threat level also should trigger a change in security habits and procedures from those followed at the previous (i.e., lower) level. To consider but one prosaic example, doors – into a bank or hotel or government office building – that are left unlocked and unattended at Green (Guarded), may remain unlocked at Yellow (Elevated), but would have an attendant monitoring access. At Orange (High), the same doors probably would be locked, and no one would be permitted access to the building without prior clearance by the attendant or a security guard.

Along with a heightened state of overall vigilance and enhanced situational awareness a number of other actions might be appropriate – and not only in the sector that has been put under a higher security level. In the wake of last week’s bombings in London the alert level for the U.S. mass transportation sector was raised almost immediately to Orange or High. Unfortunately, that might not have been enough. The reality is that any rise in the security level set for a single narrow sector may do little or nothing to help other sectors that, even if they are not the direct targets of terrorists, must deal with the consequences of a successful attack on large numbers of people.

Links, Principles, and Erroneous Assumptions

There are several links in the consequence-management chain, and there are several chains of varying lengths in the U.S. domestic-preparedness matrix. Raising the alert level for the first link in a particular chain – e.g., mass transportation – ignores the fact that the entire U.S. first-responder community, as well as the nation’s secondary and tertiary responders, might and probably would be gravely affected by a successful terrorist attack on the mass-transportation system and therefore also should be considered when the alert level is changed.

The principle involved is really, or should be, a universal one. Today, all organizations – whether they are first-responder agencies, nonprofit support organizations, or businesses – should have detailed plans in place specifying not only what to do when their own sector becomes the target, but also when a sector that they support becomes a target and/or when a sector that supports them becomes a target.

It is now more than four years since the 9/11 terrorist attacks on the World Trade Center Towers in New York City, and on the Pentagon, and more than one year since the attacks on four commuter trains in Madrid. There is therefore no acceptable excuse for any emergency-response agency – or a secondary-responder agency or organization such as a hospital – not to have developed and promulgated a detailed plan specifying how a rise in the threat level, of any sector in the overall homeland-defense infrastructure, would affect that agency or organization.

If that principle is valid, it becomes obvious that, immediately after the rise in the mass transportation sector’s threat level, all of the nation’s hospitals should have started to consider, as a matter of the highest urgency, how they would ramp up to handle the massive influx of patients flowing in from a successful attack not in London but in Boston or Chicago, Seattle or Houston, Philadelphia or Denver, or any of dozens of other major U.S. cities.

It is urgent, in developing response plans, that all hospitals know the answers to the following (and to many other questions that might be asked): (1) How should contaminated patients be cleaned and kept out of the emergency room (ER)? (2) How should the hospital deal (efficiently and effectively, and as compassionately as possible under the circumstances) with large numbers of people – many of them suffering from only minor injuries or other medical problems – who are seeking treatment at the same time, without the hospital staff being overwhelmed and losing control of the situation? (3) What is the hospital’s current surge capacity – and, of perhaps greater importance, what has to be done to activate the additional resources needed to bring more capacity on line?

Hospitals in relatively close proximity to the scene of any mass-casualty incident will inevitably be overwhelmed by those – both the walking wounded and the so-called “worried well” – who are able to walk away from the scene under their own power. While most of those who walk into the Emergency Room may require very little care – or, at worst, relatively uncomplicated care – their numbers alone might literally overwhelm an ER simply by occupying all of the usually limited space available.

Unfortunately, many hospitals continue to labor under the erroneous impression that the U.S. first-responder community will somehow or other be able to hold back this tide of suffering (and/or scared) humanity – and at the same time make sure that only those who absolutely have to pass through the ER’s doors will be permitted to do so. Moreover, those same patients, it is further assumed (by many if not all contingency planners), will show up clean and free of all dangerous chemicals. Time and again those assumptions have proven to be not only erroneous, but dangerously so.

Helpful Examples, and Some Lingering Questions

Hospitals have to have the ability to control the medical buildings and other facilities on their own property. One of the fastest ways to close an emergency room is to permit a patient contaminated with a dangerous chemical wander around the ER unattended and spread the contamination over everything and everyone in his or her wake. The only sure way to avoid this is simple – i.e., easily stated but not always easy to carry out: All hospitals must have the ability to clean contaminated patients without bringing them into the building.

Surge capacity is the term used to describe the unused portion of the hospital’s productivity or capacity. Almost every day that a hospital operates there are at least a few unused beds; this is a necessity because the flow of emergency patients who need beds is not a predictable constant.

In addition, many hospitals possess capacity that is unstaffed, and therefore unused, simply because demand is down. Some hospitals have wings or floors that are not in use; others may hold eight beds empty in an otherwise busy ward and not schedule a nurse to cover those beds.

Knowing how to activate these untapped resources is one of the keys that will allow administrators to respond to a major disaster. Unfortunately, with health-care costs still on the rise it becomes difficult to keep fiscally unproductive capacity waiting as a “just in case” asset. Most hospitals also cannot afford to pay for excess staff just to keep them available if there is an attack on a commuter train or a similar disaster affecting the local community.

The first-responder community also must be prepared to deal with increased threat levels not only within their own purview, but also within those sectors – the other links in the consequence-management chain –that could affect their own capabilities and/or productivity. If the threat level for the water supply is raised, for instance, this could activate a plan in the law-enforcement community to make more frequent passes by wellheads and water-treatment facilities.

Assigning on-duty resources to make extra patrols to protect the water-treatment infrastructure is one example of how to use existing resources more productively. Most major fire departments also are able to surge from a state of almost complete inactivity to a rapid sprint to the big fire in no time flat. Using these two examples as models, the medical community must ask itself how it should ramp up for a disaster that may not happen.

Meanwhile, city planners and administrators, and the American people, should be asking themselves an even more important question: What would the result be if hospitals do not plan for such contingencies?

Joseph Cahill
Joseph Cahill

Joseph Cahill is the director of medicolegal investigations for the Massachusetts Office of the Chief Medical Examiner. He previously served as exercise and training coordinator for the Massachusetts Department of Public Health and as emergency planner in the Westchester County (N.Y.) Office of Emergency Management. He also served for five years as citywide advanced life support (ALS) coordinator for the FDNY – Bureau of EMS. Before that, he was the department’s Division 6 ALS coordinator, covering the South Bronx and Harlem. He also served on the faculty of the Westchester County Community College’s paramedic program and has been a frequent guest lecturer for the U.S. Secret Service, the FDNY EMS Academy, and Montefiore Hospital.



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