Guest commentary by Howard W. Levitin, MD, FACEP, Assistant Clinical Professor of Medicine at Indiana University School of Medicine and Emergency Physician at St. Francis Hospital and Health Centers, both in Indianapolis, Indiana. Dr. Levitin is a frequent presenter at law enforcement conferences including the recent ADL-FBI conference in Chicago.

Recent acts of terrorism have demonstrated the incredible bravery, versatility, ingenuity, and capability of society and in particular, the law enforcement, medical and emergency response community. For example, the Oklahoma City bombing showed how victims and bystanders could quickly interface with responders to perform search and rescue to help evacuate the injured to the hospital. Survivors of the 9/11 attack on the World Trade Center can attest to the value of evacuation plans and exercises, lighted escape routes, and team work - all lessons learned from the 1993 attack on that memorable structure. The series of anthrax attacks in October of 2001 created a fear of opening mail and panic in the presence of "white powder" but it also showed how prior planning and investment in public health pays off.

These recent acts of terrorism combined with the ever looming threat have placed a tremendous burden on the law enforcement community. In addition to enforcing laws, investigating crimes, and insuring the safety of our communities, these professionals are now responsible for assessing and responding to terrorist threats. This requires more time spent on intelligence gathering and reporting, securing government and high profile facilities and venues, mass casualty planning and coordination with other response agencies, in addition to crisis management during an event.

Law enforcement officials are also being tasked to take on greater responsibility at the scene of an incident. Emergency responders depend on law enforcement to secure the incident scene, control access for their vehicles, check for secondary devices, insure evidence preservation, and the safeguarding of valuables if patient decontamination is performed at the scene. This is just a sampling of the extensive list of responsibilities designated for a group of individuals who historically lack the necessary protective gear (clothing and respiratory protection) to perform these functions. Historically, it is law enforcement personnel who are most commonly injured responding to HazMat scenes.

Law enforcement professionals may also encounter Weapons of Mass Destruction (WMD) - biological, chemical, and radiological weapons. Despite training there are often misconceptions and misunderstanding about these agents, personal safety, and the role of response teams. Let's dispel some commonly held myths:

• We are all unprepared (and going to die) - not true.

• Biological agents are easy to acquire, grow, and disseminate - they're not.

• A chemical weapons attack will cause mass casualties - the vast majority will survive without consequence.

• Antidotes need to be given at the scene of a chemical incident in order to save lives - few antidotes are available and are rarely useful at the scene unless immediately administered.

• Any exposure to radiation causes cancer - simply not true.

• Federal response teams will arrive quickly to help out - the initial response will all be local.

It is important for law enforcement personnel to have a general understanding of the various terrorist agents for self protection (including peace of mind) and better functionality at the scene:

• Biological Threat - bioterrorism is the deliberate release of microbes and toxins to produce disease and epidemics. Most of the agents are not contagious (anthrax), though a few such as smallpox and plague are able to spread person-to-person. If a biological attack does occur it may not be immediately obvious. The initial signs and symptoms are often delayed and non-specific. Actual identification first requires healthcare providers to recognize and report a pattern of unusual illnesses and complaints. Once suspected, the initial information made available to the public will be limited, speculative, and non-specific. If a bioterrorism event is declared, there is no need to rush to the doctor; remain calm and access the news for additional information and instructions.

  A surgical-style mask (or particulate filter mask) combined with good hygiene (hand washing) will provide a high degree of protection against those agents that spread person-to-person. If prophylaxis or vaccination is advised, don't advise people to rush to the hospital or their doctor's office; medicine and vaccines have been stockpiled for these purposes and will be made available through the public health and medical system. You actually have a few days before it needs to get started.

• Chemical Threat - a chemical attack is the deliberate release of a toxic gas, liquid or solid that can poison the surrounding population and environment. Historically, all large scale chemical releases involved vapors and aerosols that are impacted by a number of environmental factors (wind, temperature, and sunlight). By simply evacuating the area of the release you almost always leave the risk. If evacuation is not possible, advise people to simply stay indoors and close all of the windows. Afterwards, tell them to go home, remove and wash their clothing, and take a shower. If symptomatic, they should go to the hospital. A few important take home messages:

  • DO NOT enter the scene with downed victims

  • DO NOT enter a contaminated area without appropriate PPE

  • A particulate filter mask will only protect against particles, not chemical vapor

  • Evacuation & clothing removal first

  • Fresh air is the BEST antidote

  • Other antidotes are few & rarely needed

  • Respiratory protection is necessary for all personnel remaining at the scene

• Radiological Threat - a dirty bomb is the use of common explosives to spread radioactive material over a targeted area. This combined weapon is not a nuclear bomb and will not cause a nuclear reaction. It will minimally impact the cancer rates in the affected area. The biggest risk from a dirty bomb is from the explosion itself and the negative economic impact it will have on the affected community.

  A nuclear bomb, on the other hand, is an explosion with intense light and heat, a damaging pressure wave and widespread radioactive material that can contaminate air, water, and ground surfaces for miles. Although devastating, it is survivable. It is important to take cover to protect against the blast wave. One's personal risks of radiation exposure are reduced if one minimizes the time spent at the scene, maintains distance from the source, and wears protective gear. Only enter areas that are deemed safe and always wear a radiation dosimeter so your exposure can be monitored.

• Explosive Threat - an explosion is an instantaneous chain of events in which an explosive material is rapidly converted into a gas under extremely high temperatures and pressures producing a blast wave. It's the blast wave and associated debris that produces most of the injuries. In the majority of bombings those that survive the explosion do well. It is important to immediately evacuate the area (avoid using the elevators). Secondary bombs are not uncommon. Seek medical care for injuries and physical complaints. A particulate filter (surgical-style) mask will provide adequate respiratory protection against particulates generated from the explosion (also true for dirty bombs and nuclear explosions).

Finally, law enforcement professionals are vital members of the community and they should help reduce society's anxiety and fear about terrorism by encouraging people to learn more about preparedness (www.ready.gov), volunteer for organizations such as the Red Cross, Salvation Army and Citizen Corps (www.citizenscorps.gov ), and create a family disaster plan that includes a mechanism for family members to stay in contact in case of an emergency. A great resource is the Family Readiness Kit (www.aap.org/family/frk/frkit.htm) that is endorsed by the American Academy of Pediatrics.

Take home messages:

• Don't enter a hazardous environment without appropriate information and protection - responders are wearing protective gear for a reason.

• DON'T forget abut relationship building - get to know members of your public health, medical, emergency management, and emergency response community. All are involved in planning and response.

• DON'T become a victim - insure you have appropriate protection and training

• DON'T forget to find time to get away - you have a stressful job; make sure you aren't neglecting your own physical and mental health