Staged at the National Naval Medical Center (NNMC) in Bethesda, the drill began when a suicide bomber used fake identification to drive into the base and then to the NNMC ball field. The car struck several people at high speed as it entered the field and exploded among approximately 70 personnel and family members attending a Uniformed Services University of the Health Sciences picnic. Many, including the car's driver, were killed or injured by the blast. Radiation from it contaminated many more, who soon developed symptoms of acute radiation syndrome (ARS), compounding their injuries.

Two minutes after the blast, Base Security received an anonymous telephone call warning that the base is under attack and that all aboard would die. So it seemed to victims at the scene, one of whom yelled repeatedly, "Run! Run! We’re all going to die!" Another casualty, bleeding from her head and arm, ran to and fro shouting, "Where’s my son? He was with me a minute ago!"

Five minutes after the blast at NNMC's ball field, the first Base Police cruiser to arrive on the scene radioed to Dispatch that a car was ablaze on the ball field, multiple casualties were on the ground near the vehicle, and panic was spreading among dozens of walking wounded. Base Fire was notified that use of a "dirty bomb" was a possibility and that HAZMAT (hazardous materials) specialists should be sent immediately. Police cordoned off the ball field and cleared a narrow road leading to its parking lot for fire trucks and ambulances, which began arriving 25 minutes after the blast. Panic reigned as the hysterical among the walking wounded ran toward arriving emergency vehicles, pleading for help.

Captain Mark Olesen, NNMC's deputy commander, activated the base's Mass Casualty Response Plan (MCRP) soon after receiving reports that multiple explosions also had occurred at the Rockville Shopping Mall and the Shady Grove Metro Station. The plan involves close coordination among Suburban Hospital, a community-owned facility serving Montgomery County; the National Institutes of Health (NIH), an agency of the U.S. Department of Health and Human Services; the National Naval Medical Center, part of the Department of Defense; and Montgomery County Emergency Services to share treatment of casualties during an unexpected surge to area hospitals.

Decontamination
Because first responders suspected that a radiological dispersal device (RDD, also known as a "dirty bomb") had been detonated, the scene had to be checked for radiation contamination before medical personnel could treat victims. Two specially equipped firefighters entered the cordoned ball field with radiation detectors. After finding higher-than-normal levels of radiation, they radioed for a "gross decon" tent to be erected within the field by HAZMAT personnel, wearing protective clothing.

Live victims were carried on stretchers to one end of the tent and their stretchers loaded onto a waist-high platform of rollers. Each stretcher was rolled to the tent's opposite end as the victim’s radiation-contaminated clothes were removed, body examined for wounds, and then spray-washed with soap and water to remove surface radiological contamination. Those two simple procedures are effective for removing over 95 percent of a patient's external contamination, according to AFRRI's Colonel William E. Dickerson, a physician and expert in the medical effects of exposure to ionizing radiation.

Photo: W. Dickerson (AFRRI)

Personnel at the disaster scene's "gross decon” station remove surface radiation contamination from victims, who are then sent to hospitals.

"Victims of radiological contamination don’t die immediately of the radiation injury," Colonel Dickerson explained. "It is important to take care of life-threatening injuries first and then decontaminate."

After clearing "gross decon," victims were carried to ambulances for transport to the Suburban and NNMC hospitals. Suburban received and treated 35 casualties and NNMC 30, including several deceased victims. Suburban, which has a Level II trauma unit, requested that the National Institutes of Health accept 10 of its post-surgery patients to make room for other incoming casualties from the disaster scene. Because one among the walking wounded at the picnic was a physician, he was able to direct EMS personnel regarding which victims required immediate care and which could wait.

All casualties wore large tags listing the specifics of their wounds, their vital signs, and what treatment (if any) they’d received at the scene and during transit. This enabled the drill to test not only the skills and adaptability of first responders but also those of first receivers at the three hospitals involved. Victim decontamination was performed at the "gross-decon" field station and at a “fixed-decon” facility outside NNMC hospital's emergency room.

Find and fix flaws
To further stress and test the adaptability of its mass-casualty response teams, the drill's organizers built surprises into the day’s events. For example, 18 of the walking wounded who had been far enough away from the terrorist's car to escape radiological contamination were nevertheless exposed after being grouped with contaminated patients by first responders who, owing to on-site panic among victims, couldn't always tell the difference. Second-hand contamination necessitated that those patients be decontaminated at fixed facilities set up outside NNMC's emergency room.

Photo: D. Morse (AFRRI)

Firefighter assesses a victim's condition.

Drill organizer and NNMC Disaster Preparedness Officer Navy Lieutenant Chris Gillette, asked by a TV journalist why ambulances took 25 minutes to arrive, cited the need to challenge the plan to find and fix its flaws. "That is one of the dilemmas with a potential radiation exposure: We need to first clear the scene safely so our emergency-response teams can enter the scene."

Only visible life-threatening injuries were treated at the disaster scene’s "hot zone." Once firefighters' radiation detectors confirmed that a dirty bomb had been detonated, decontaminating victims became a priority before they could be moved to hospitals for treatment. Because exposure to radioactive material from the victims and their clothing could contaminate EMS as well as hospital personnel and patients, "decon" was the top priority at the disaster's hot zone and again as victims arrived at NNMC Hospital.

The drill demonstrated the variety of challenges facing first responders and first receivers of mass casualties from a radiological incident. Victims pleaded with firefighters, ambulance personnel, police, and even with other victims to treat their wounds or those of injured loved ones, and to help them find lost coworkers and family members. Other victims were conscious but unable to stand or talk owing to psychological shock and physical injuries.

'Weapon of mass disruption'
Had the day's drill been the real thing, family and friends of victims would arrive at hospitals frantic as disaster news spread via live broadcasts from circling media helicopters. With the attack's extent yet unclear, base security personnel were on maximum alert to prevent other terrorists from entering. If the disaster were real, media reporters would gather at hospitals and at NNMC gates, demanding access. NNMC, Surburban, and NIH public-affairs offices would be deluged with telephone calls from community residents worried about loved ones and themselves.

Photo: D. Morse (AFRRI)

Medical personnel at NNMC Hospital's "fixed decon" facility use radiation detectors to gauge an incoming victim's level of contamination.

AFRRI's Colonel William E. Dickerson, at a presentation made with Navy Lieutenant Commander John L. Crapo to NNMC medical personnel before the day's drill began, described how "significant psychological impact" is a major goal of terrorists. The radioactive material dispersed by a dirty bomb is likely to be low level, he said—but the resulting mass panic and stress on medical services would be significant.

"That is why dirty bombs are known as 'weapons of mass disruption'," Colonel Dickerson explained. "A radiological dispersal device is not a nuclear weapon. It is not a weapon of mass destruction. It is a cheaper way to injure while creating mass panic among the target population. Its impact depends on the type of explosive, the amount and type of radioactive material, and weather conditions." And a dirty bomb's components are obtainable, Colonel Dickerson added. "To build a crude RDD, you need an explosive plus radiological material. Such material is available in many medical and industrial facilities."

A statement from a Defense Science Board report, titled Preventing and Defending Against Clandestine Nuclear Attack, underlines the importance of NNMC's Mass Casualty Exercise. "Today, it would be easy for adversaries to introduce and detonate a nuclear explosive clandestinely in the United States."

As part of NNMC's Command Disaster Conference, which ran from 7:30 to 3:30 p.m. concurrent with the Mass Casualty Emergency Disaster Drill, a series of lectures given by noted medical authorities were held and 24 “skill stations” visited by NNMC staff (medical and nonmedical). Lectures included "Handling of Traumatic Stress During Crisis," "Nuclear and Radiologic Terrorism," and "SARS/Avian Flu." Skill-station topics included Burn Management, IV Basics, Wounds Care, Chest Trauma, Infectious Disease, Pediatric Trauma, and Automated External Defibrillator.

Goals achieved
Captain Mark Olesen, deputy commander of the National Naval Medical Center, explained the drill's importance for defending against an actual terrorist attack. "With this training, each of our staff members will have a clear idea of what to do in the event of an emergency."

Some 30 emergency-response teams participated in the daylong exercise, including those from NNMC, Walter Reed Army Medical Center, Montgomery County Fire and Rescue Services, and the NIH's HAZMAT squad. NNMC staff formed response teams: Triage, Immediate Care, Delayed Care, Minor Care, Expectant Care, Expired Unit, Operating Room Unit, Emergency Operations Center, the Family Reception Center to link victims with concerned families, and the Command Information Bureau to coordinate communication between civilian and military authorities.

Navy Commander Sarah Kirtland, an AFRRI health physicist serving as one of about 30 drill evaluators, was posted close to the action at the disaster scene's hot zone. She came away impressed by the plan’s main goal of improving interoperability. "It was wonderful to see a radiation incident included in the training," Commander Kirtland said. "Planning for and practicing scenarios for chemical, biological and radiation—an all-hazards approach to terrorist incident response—helps ensure that all players are prepared. The National Naval Medical Center, National Institutes of Health, Suburban Community Hospital and the Montgomery County Emergency Management Services are prepared to work together smoothly to bring the best medical care in the shortest amount of time to the victims of an attack."

Navy Lieutenant Chris Gillette, NNMC's disaster preparedness officer, likewise stressed improved coordination as the drill's key goal. "Partnering with Suburban Hospital and NIH—this is the future of casualty-care management."

Colonel Dickerson summarized the day's goals for AFFRI personnel:

• Test and evaluate first responders, including procedures used to identify a bomb's radiological agent, triage, and execution of gross decontamination;
• Test and evaluate first receivers comprising newly established Radiation Decontamination Teams to accomplish fixed-decon at receiving hospitals and control the flow of contaminated versus noncontaminated patients; and
• Test the interoperability of NNMC, Suburban and NIH hospitals as well as military and civilian emergency-response personnel. Interoperability being the drill's prime goal, it includes testing notification and communication of an emergency, determining equipment and supplies needed at each location, and evaluating the patient-tracking system in place at each facility.

"Such a large-scale exercise enabled AFRRI evaluators to practice what they teach as regards preventing and treating the biological effects of ionizing radiation," Colonel Dickerson said. "It is theory versus practice, coursework versus its application tested via an integrated approach. We’ll take lessons learned here back to the classroom to improve both our theory and our teaching."