Opinion & Comment:
MEDICAL CHALLENGES OF TERRORISM AT SEA: A
CALL TO ACTION
By: Dr. Joanne McGlown, R.N., M.H.H.A, Ph.D.
(Published October
2003)
Ships and ports are vulnerable to attack – of any nature. Whether from a chemical or biological agent release, an explosive or radiological dispersion device ("dirty bomb") or nuclear weapon, the nature of the maritime trade, current preparedness levels at shore side facilities worldwide, and the potential to inflict harm through the use of a maritime vessel are too great to ignore.
The events of September 11 have resulted in sweeping changes in our lifestyle, and forced a higher standard of emergency preparedness on global industry. We operate in an environment of risk which precludes our right to function as we did in earlier times. The famous saying "If you always do what you’ve always done, you’ll always get what you’ve always got" has never been more evident than when addressing the medical aspects of emergency preparedness of our nation.
Under rules issued by the Department of Homeland Security ("DHS") July 1,st about 10,000 ships and 5,000 coastal facilities will be tightening security against the threat of terrorism, with much of the cost borne by the maritime industry. The steps of assessing vulnerabilities, hiring and training security officers, buying security equipment, establishing security committees, drafting security plans and holding training drills and exercises are long overdue; however, medical preparedness has not been recognized at the level it deserves. The warnings from terrorist groups have been frequent and clear, and no terrorist tactics should be overlooked.
As experienced with the ACHILLE LAURO and USS COLE, maritime interests are perfect targets for hijacking, hostage taking, explosions, chemical releases and sabotage, and with these come the potential for mass casualty and death. The medical implications of such are staggering.
Preparing for acts of terrorism requires extensive and thorough planning, preparation and training from all, but perhaps none more urgent than from the medical services at sea. Detailed medical plans for disasters and catastrophes, coupled with extensive training and education, designed in collaboration with local responders and emergency management agencies is critical.
From Norwalk to SARS
Medical crises from viruses or biological agents can claim many victims and severely tax the limited medical resources available. Major outbreaks of the Norwalk-like virus illustrated just how quickly and easily the viruses spread, especially when many people are packed into confined areas. Extremely contagious, the virus can be avoided through minor hygiene practices, though ridding ships of the virus proved a great challenge. Yet, it was SARS (Severe Acute Respiratory Syndrome) that left the world wondering if travel was worth the risk.
SARS is an atypical pneumonia illness of unknown origin, with an incubation period between exposure to infection and development of symptoms ranging from 2-7 days. The disease is limited in scope with a mortality and at-risk population considerably lower than other diseases; however officials have been unable to determine the agent causing SARS. There is no certain treatment, vaccine or known preventative measure, and the risk to those working in the transportation and healthcare industries is undeniable. Transmission is swift and lethal. In mid-March, 2003 there were 350 SARS cases and 10 deaths. By early June, SARS had seen a cumulative total of 8,402 probable cases with 772 deaths reported from 29 countries.
The greatest threat, though, is perceived to be from a future global influenza outbreak. In an influenza pandemic, the number of cases could run into tens of millions and the deaths into millions. The disruption to businesses caused by such an outbreak would be many times that of SARS. The threat of a deliberate terrorist-induced epidemic is also real, as is the easy availability of weapons grade biological agents.
By Land or By Sea
Maritime vessels are at risk: 1) in port (domestically or internationally); 2) in territorial waters, close enough to shore to mobilize rescue or assistance, and 3) on the high seas. Medical plans for maritime companies should treat each environment distinctly, for the rescue, response and medical assistance availability will be dictated by location, among other factors.
Who Will Come?
This will differ by location. At port, a plethora of local emergency services stand ready to assist, and most maritime agencies have wisely planned preparedness and response and recovery activities in conjunction with local providers. However, terrorism is a federal crime in the U.S.; thus, responding agencies will differ. Law enforcement at the local, state and federal level will respond to suspected terrorist events. It is important to remember, however, that all disasters are local. The immediate response is provided by local services; thus, it is imperative that extensive medical plans involve the development of relationships with these providers. The services provided by responders will be directly related to the levels of collaborative training, education, and trust developed over time. With minimal effort, cruise lines could greatly improve and maximize the capabilities of responders.
Medical Assets
Medical and support staffs are often part-time, may not be thoroughly integrated into or aware of the ships’ disaster plans, and may have no background or experience in disaster or mass casualty care. Frequent and high turnover rates among medical and healthcare delivery staffs make training and retention of a qualified medical disaster response team extremely difficult. However, these issues do not lessen the importance of the problems. A review of corporate policies concerning medical services, the qualifications of staff, rotation of personnel and their responsibility to develop or enhance existing medical disaster planning to include potential terrorist events should be undertaken. The Cruise Medicine section of the American College of Emergency Physicians ("ACEP") has established guidelines and accepted standards for medical care onboard cruise ships, and should be the organization to address present and future needs to adequately prepare medical staffs for all-hazards disasters and mass casualty situations, including terrorism.
Developing a "Disaster Culture"
While the maritime trade takes safety issues very seriously, this focus on safety (prevention) must not exclude the preparation for response to catastrophic events. In a disaster culture, crew, staff and officers place emphasis on preparedness for "all-hazards disasters" and corporations value and reward continuing education, training and exercises, and integrative planning efforts through a primary corporate mission of readiness. This is extremely important in the maritime trade, where frequent rotation of personnel and turnover may create an environment of greater risk than seen shoreside.
As Strong as the Weakest Link
The medical sector has been called America’s "weakest link" in the battle against terrorism. Agencies may have excellent general safety plans, but poor-to-nonexistent mass casualty plans. Ships must integrate their plans with local response agencies and authorities to ensure success. Statements gathered in recent interviews with leaders of primary emergency management and law enforcement agencies to one of the largest cruise and cargo ports in the U.S. included statements such as "we assume that they have a plan, but we haven’t seen it," "we assume the Captain will invite us onboard to provide assistance, though he/she doesn’t have to," and "we would like to know what they perceive our capabilities to be and how we can best assist them." Although there are certainly exceptions, compared to the extremely high level of interoperability and familiarity of the land-based emergency management community that comes from decades of mutual aid assistance, collaborative planning, integrative drills, training, and exercises, the awareness that the maritime industry may not be "at the table" at the same or similar level of performance is of concern.
A very strong internal disaster plan is a necessity for incidents on the high seas. Other disaster occurrences require planning that extends beyond the confines of each vessel to embrace outside emergency response agencies for a multitude of contingencies.
Hidden Assets
For cruise lines, extremely limited medical resources may be augmented from among the passenger base in a crisis. Nurses, doctors, and other healthcare specialists, as well law enforcement officers, engineers, and military officers offer a treasure trove of skills and training beneficial in mass casualty situations. If cruise lines are not prepared to integrate them into a functional response system, this may be the time to consider such a plan. Simple actions would allow ships to capitalize on resources that may be desperately needed in mass casualty situations.
Think Big Thoughts
Disaster planning and preparedness is not difficult, but many maritime plans stop at fulfillment of SOLAS or requirements of other regulatory agencies. Medical crises require that cruise lines and other maritime agencies plan for issues that fall outside these regulations: quarantine, mass decontamination of the vessel or passengers, mass trauma or burns, mass respiratory distress, incapacitation of the officers or crew, or medical mass evacuation of the sick or injured. Existing plans should be re-examined to ensure they are complete, detailed, realistic, and operational. Plans should reflect a sophisticated level of integrative planning with shore side responders, including the CDC, FBI, Coast Guard and medical facilities in frequent ports of call. Logs should document all training (on shore and onboard), drills and exercises. Training, provided by experts with knowledge of the maritime trade, should cover all potential disaster events. Medical staffs should receive focused training on the emergency management systems of each port of call, responding agencies to events at port and at sea, and detailed instruction on the process and specifics of mass decontamination, quarantine, and evacuation. If medical departments lack disaster plans that encompass all hazards and disasters (including acts of terrorism, or potential use of weapons of mass effect ["WME"] ) the time is ripe to address these issues.
Who is Welcome Aboard?
Local and area emergency managers may be uncertain whether the Master of a ship will invite them to board to offer assistance in disaster situations. This issue should have been addressed eons ago, by every ship and every Master, in every port in the nation. Recognizing this as an individual Master’s right, if the Master does not intend to allow assistance, local emergency managers must know so they can plan today to take alternative precautions to protect those at risk from events on or around the vessel. Risk managers and legal counsel should also be informed of this intent, so they can assist the line in their decisions and the potential aftermath following a crisis. Likewise, if assistance will most likely be allowed, it is imperative that discussions and plans be initiated ASAP to forge a collaborative working relationship with those who will respond when called. The secrecy surrounding this issue is dangerous when addressing potential terrorist events. Response time and the urgency of sophisticated levels of coordination should never be delayed by such uncertainty.
Toward An Improved Healthcare Delivery Standard
Admiral Tom Collins, Commandant of the U.S. Coast Guard, discussed the U.S. maritime homeland security strategy consisting of seven principal elements. It is appropriate to propose a maritime healthcare delivery strategy designed to improve the ships’ medical capabilities for response and recovery based on this exact strategy. These include: 1) maintaining an increased level of medical disaster preparedness; 2) strengthening the skills and abilities of medical staff to respond to potential disasters; 3) creating a comprehensive medical threat assessment and medical hazard vulnerability analysis to use as a baseline for preparedness improvement (for each situation and at each port); 4) expanding emergency and disaster response core competencies of physicians, nurses and medical staff aboard ships and/or at ports; 5) identifying appropriate stores of medical materials and supplies for all-hazards events; 6) preparing for transition from daily passenger and crew medical care to disaster medical operations and recovery, as needed; and 7) organizing and sustaining a lasting partnership between the ships’ medical staffs and portside medical facilities and first responders.
Dr. McGlown is an RN and legal nurse consultant, hospital administrator, researcher, and adjunct professor in graduate and undergraduate Emergency Management. She holds an M.H.H.A and Ph.D. in Administration – Health Services from the University of Alabama at Birmingham and additional degrees in Fire Science Administration and Emergency Medical Services. She is Lead Medical Researcher for Battelle Memorial Institute (Crystal City, VA) and is the CEO of KJMConsulting, a healthcare management firm specializing in emergency and disaster preparedness and response. She has been employed with the Federal Emergency Management Agency ("FEMA") in Washington, D.C., with the global consulting firm of Ernst & Young, and as a cruise nurse with Holland America Line.
