Mass casualty drill challenges health system

A dirty bomb went off in Seattle. A plague was let loose in Chicago. Now officials are tallying the lessons learned from the test.

By Victoria Stagg Elliott, amednews staff. June 2/9, 2003.

On a Monday in May, while workers are taking their lunch break in Seattle's downtown, a dirty bomb exploded, directly injuring 100 and terrifying many who feared exposure to residual radiation. Meanwhile, that evening in Chicago, travelers and hockey fans started showing up at hospitals, coughing up blood.

Wait. Don't panic. It was only a drill.

Evaluating disaster drills
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The U.S. Dept. of Homeland Security's Top Officials 2 -- TOPOFF 2 -- designed these two simultaneous scenarios to test the ability of hospitals and the public health system to respond to a radioactive bomb and the release of a biological agent.

The drill carried a price tag of $16 million, making it the most expensive emergency preparedness exercise ever. It was also the most comprehensive, and attempted to apply lessons learned from TOPOFF 1 which took place three years ago.

"We hope TOPOFF 2 will provide us with concrete examples of how we can better respond to attacks," said Homeland Security Secretary Tom Ridge. "Because, while we're doing everything we can to prevent, deter and disrupt terrorist activity, we have to be prepared to respond to any real-life scenario that might occur."

The Chicago experience

Imagine what it was like. For three days, dozens of Chicago-area hospitals received faxes detailing the circumstances of pretend victims. Some of these -- actually volunteers wearing bright yellow T-shirts emblazoned with the words "Role Player" on the back -- showed up in person and mixed with the hospitals' real patients. Hospital workers tried to attend to the needs of both. Periodically, a role player would pull out a card marking him or her as dead.

By Wednesday, the made-up terrorist organization GLODO claimed responsibility for the Seattle situation. The same group also took credit for the release of pneumonic plague at the hockey game at a Chicago stadium as well as the city's train station and at O'Hare International Airport.

The TOPOFF 2 drills in Seattle and Chicago cost $16 million.

Thus, in Chicago, the public health information campaign began: A plague had been released. The messages encouraged those who may have been exposed to report on Thursday to a temporary clinic set up at a nearby high school. This site would provide antibiotics for those at risk.

More than 500 volunteers -- more role players -- gathered at these ad hoc clinics. All were given note cards describing who they were and the circumstances of their exposure.

One card outlined the identity of Easter Prince, a woman who "stepped out" to the hockey game with a secret boyfriend, leaving her husband at home with her children. She has to obtain antibiotics for her entire family because now they are all at risk.

The health workers ask whether anyone is experiencing fever or chills. They also remind volunteers to stay in character. Some volunteers have been directed to ask lots of questions. Others require Polish or Spanish translators. Still others are panicked or begin to show symptoms such as coughing. They are lined up and handed masks while they wait for an ambulance to take them to the hospital. The ambulance never arrives.

Eventually people with a known exposure are escorted to a triage area. Easter Prince is one of them. It is so crowded in this area that most have to stand while they answer more questions about possible symptoms. Those deemed OK for now, like Easter Prince, are sent to another room for an 11-minute educational video about plague. This group is then escorted to the dispensary to complete forms detailing basic health information.

Getting accurate information at this stage presents some challenges for the health care workers. For instance, Easter Prince has no idea what her children's weights are -- vital for an accurate prescription. The public health workers must coax an educated guess out of her.

Ultimately, Easter Prince must wait in another line for doxycycline pills for herself and her husband. Her children will be given liquid formulations. Once having completed this process, she takes the first dose -- a piece of candy -- in front of a public health worker. The whole experience lasts about an hour.

Early reviews

In many ways, this part of the drill mimicked a real temporary clinic distributing vaccines or prophylaxis in response to a deliberate or naturally occurring infectious-disease outbreak. Volunteers got testy in the long lines, and it wasn't always clear where the "victims" were supposed to go or what they should be doing.

"This was our chance to test the system," said William Paul, MD, MPH, deputy commissioner of the Chicago Dept. of Health.

"You have to do that," agreed James J. James, MD, DrPH, MHA, director of the AMA Center for Disaster Medicine and Emergency Response. "It's not an investigation. What you're testing is capacity within the system, but more importantly the capacity within different agencies and systems to cross-communicate and act together. The closer you come to making it realistic, you really are inviting injury or panic."

In this instance, the public health department and the hospitals knew what was coming, although not necessarily exactly when and how many people. Also, volunteers tended to be fairly calm and happy. Those reporting to clinics like this may not be as good-natured in a real situation. Also, all the volunteers were playing people who were supposed to be there. They were at risk and needed treatment or prophylaxis. In a real event, the public may not screen themselves quite so well.

"All of a sudden, you've got a large number of people who want to receive the medication but didn't receive the message or who weren't in the target group," said Dr. James, who was among those volunteering in the drill. "That just adds to the pressure on the system. It adds to the anxiety, and that's where I get concerned."

Data gathered from TOPOFF 2 will be analyzed over the next few weeks to determine what worked and what didn't. Are there things that could have gone faster? Did Easter Prince really need to spend a full hour from presentation to first dose of medication? And the question remains: After all this time and money, are we ready?

"I don't think anybody ever feels ready. You feel slightly more confident, and I'm glad we practiced," said Sally Reynolds, MD, who participated in the drill and is co-chair of the disaster planning committee of Children's Memorial Hospital in Chicago.

Note: Elliott was among the dozens of AMA employees who volunteered to participate in the Chicago portion of TOPOFF 2 the week of May 12. She played the role of Easter Prince.

ADDITIONAL INFORMATION:

Evaluating disaster drills

Is disaster practice really making perfect?

Emergency physicians at Johns Hopkins University in Baltimore and Loma Linda University School of Medicine in California have devised protocols to evaluate disaster drills, according to last month's Annals of Emergency Medicine.

"Disaster simulation drills are widely used throughout the world and are considered a fundamental tool to evaluate and improve local disaster response," said Gary B. Green, MD, MPH, lead author and an associate professor of emergency medicine at John Hopkins.

"Despite this, however, no generally accepted methodology had existed to evaluate the medical response to a disaster. We created a set of tools that are flexible enough to be practical for disaster planners worldwide," Dr. Green said.

Researchers tested their methods during a disaster drill in Guatemala City last year.

In their scenario, a propane tank exploded in a walled courtyard next to a government building. Fictional casualties suffered trauma and severe burns. The location several blocks from a main thoroughfare made it difficult for ambulances to reach.

The drill's efficiency was determined by measuring how long it took to develop a command structure for the site, to deliver on-site care to victims and to notify local hospitals to expect large numbers of wounded. The quality of care delivered was also measured.

Researchers determined that, in this instance, security at the hospital needed to be improved. Health care workers also needed to be better educated about their roles during a disaster.

Authors of the paper designed the evaluation methods for developing countries that are most affected by disasters but expect that the system could be used anywhere.