While infectious disease, cyberattacks, and workplace violence may be the most emergent threats to hospitals, the risk of a chemical, biological, radiological, nuclear, or high-yield explosive (CBRNE) event is ever-present. A biological or radiological terrorist attack may seem unlikely, but hazardous materials are abundant around and inside every hospital. CBRNE materials are used in factories and on farms. They are transported by vehicle and rail. The hospital itself contains any number of contaminants, from the radioactive materials used in nuclear medicine imaging, to chemotherapy waste, to cleaning chemicals. Exposure to these substances can lead to everything from irritation to the skin and eyes to cancer.
FEMA’s Hospital Emergency Response Training
The Hospital Emergency Response Training (HERT) for Mass Casualty Incidents course is offered by the Federal Emergency Management Agency (FEMA) at the Center for Domestic Preparedness (CDP) in Anniston, Alabama. Twice a month, healthcare personnel learn to recognize the signs and symptoms of a CBRNE event. They use the Hospital Incident Command System (HICS) to assemble a team, select the appropriate personal protective equipment (PPE), perform mass casualty triage, and decontaminate patients exposed to hazardous materials. Full Type B Hazmat protection used in the exercise included: Tyvek suit, icepack vest inside, rubber boots, rubber gloves, shroud, and powered air purifying respirator.
This first-hand account describes what it was like for one participant inside a realistic hospital training facility.
Students participate in three 10-hour days of classroom training on recognizing the indicators, health effects of exposure, and treatment protocols for CBRNE events. On the fourth day, students participate in a full-scale exercise in which they don the appropriate PPE, set up an emergency treatment area, and triage and decontaminate mock victims. The simulation is designed to be as authentic as possible and introduces students to the decontamination process, including the physical and psychological stress on first receivers. After the course, students can stay an extra day to become certified trainers for their teammates at home.
The course is designed for emergency managers, clinicians, security teams, housekeeping staff, and others who may be called upon to respond to a mass casualty incident at their hospitals. The only prerequisites are FEMA’s no-cost online Independent Study 100, 200, and 700 courses. Like other in-person FEMA training, the course is entirely free, including travel to and from the CDP. Once a student is accepted, all travel arrangements are handled by FEMA. The campus is about 90 minutes outside Atlanta on the campus of the former Fort McClellan Army installation. Students stay in dormitories and take their meals in a cafeteria. The campus “Recovery Zone” lounge provides a way for students to unwind at the end of the day and team-build with their classmates.
It is 85 degrees in Alabama, and the noon sun is beating directly overhead. I am sweating in a head-to-toe Tyvek Suit with a respirator shroud sealed around my head. I can only see what is directly in front of me. One of my ankle socks has slipped down and squished into the toe of my huge rubber boot, but there is no way to retrieve it without completely removing everything, a ten-minute process requiring assistance. I’m wondering how long I can stand to wear this PPE, let alone function in a hands-on role.
I am working in a mock emergency treatment area established for a fictional mass casualty incident in which victims of a terrorist attack were contaminated with nerve gas following an explosion. A large yellow tent is equipped with garden hoses, buckets of dish soap, and a conveyor belt for stretchers. Earsplitting ambulance sirens wail. Volunteer “patient” actors writhe and call out for attention. Stretchers roll past strapped with mannequins, both adults and children. Some have severe burns and amputations; most are covered in blood.
I have been assigned to the ambulatory triage line. My job is to prioritize the walking wounded; they must disrobe, enter a shower inside the tent, and scrub themselves with soap. I soon regret writing my name on the outside of my shroud as the patients now call out for me and demand I personally move them to the front of the line. I send through a pregnant woman in labor. She wears an artificial belly with a doll’s head emerging from the bottom and squeezes an IV bag to simulate her water breaking. I triage the next patient. He has a severe arm fracture, so I send him through. Skilled makeup artists have created a jagged prosthetic bone emerging from his skin and covered it in red corn syrup. I usher him into the “outer garment doffing station,” as simply removing a patient’s clothing can remove 60-80% of contaminants. He points to his t-shirt. It’s all black with two words in large white lettering: I’M NAKED. I break character, laugh, and direct him to the next station since he has (technically) already disrobed. As he goes, his prosthetic arm wound falls to the floor. He shrugs, carefully reattaches it, and moves into the shower.
After a quick break where I finally get to take off the shroud and chug a bottle of Gatorade, I move to a different station. My new job is to decontaminate non-ambulatory patients on stretchers. The mannequins have sustained incredibly gruesome injuries from the explosion. We cut off the patients’ clothes, carefully wash their bodies and faces, and re-tie their tourniquets. The simulation becomes almost too real when the triage team pushes a baby with a black tag down the conveyor belt in a bathtub. The baby’s mother tries to stay with the body, but she is not permitted inside the tent. When we bring the baby out, we try to explain what has happened, but it is not much consolation.
As we finally doff (take off) our Tyvek suits and boots, wring out our soaked clothes, have our vital signs checked, and debrief from the incident, I realize that this exercise has been one of the most intense experiences of my life. In fact, the course is the best training I have ever received in 20 years as an emergency manager.
The five HERT instructors were dedicated subject matter experts with years of experience who could confidently answer any question posed by the class. The class size was limited to 30 people, split into small groups, and it was energizing to be in a room full of healthcare first receivers who could relate to the daily challenges faced in that setting. The classroom training provided an almost overwhelming amount of theoretical knowledge, but the daylong simulation made that knowledge real, understandable, and applicable. The simulation was so realistic, so demanding, and so genuinely stressful that it created a dramatic shift in my perspective as a hospital emergency manager. The course resulted in a notebook full of new ideas and an actionable plan to strengthen the University of Maryland Medical Center hospital’s decontamination program.
Stretchers lined up for triage/decon (Source: Valentine, 2022).
More information on the HERT course is available at https://cdp.dhs.gov/training/course/PER-902.
Publisher note: In June 2015, Domestic Preparedness was invited to take an exclusive inside look at the CDP training facility, which offers something that could be beneficial to any readers of the Domestic Preparedness Journal. A comprehensive supplement can be found at https://domprep.com/journals/train-for-real-life/
Erin Valentine is an emergency manager at the University of Maryland Medical Center, a 700-bed teaching hospital in Baltimore which houses the nation’s first shock trauma center. She spent the first decade of her career at the Maryland Department of Emergency Management (MDEM) and went on to support the Social Security Administration as a Continuity of Operations/Continuity of Government specialist. She then spent five years as a business continuity and IT disaster recovery consultant for the Centers for Medicare and Medicaid, the National Institutes of Health, and the Johns Hopkins Hospital. She transitioned to healthcare emergency management in February 2020 and lead the hospital incident command team’s response to the COVID-19 crisis. She is studying for a master’s degree in Emergency Management at Clemson University and is certified by FEMA as a Master Exercise Practitioner (MEP) and Professional Continuity Practitioner (PCP). She is a Certified Business Continuity Professional (CBCP) and is the president of the Central Maryland Chapter of the Association of Continuity Professionals.