What Can Nurses Do to Prepare for Terrorist Acts?

by Mary Theresa Urbano, PhD, RN

September 11, 2001 is a date etched in the memories of Americans forever.

Prior to that date, most Americans did not spend much time thinking about terrorism. Who could have imagined attacks that would use civilian airlines as missiles for mass destruction? Who could have imagined that two of the country’s major landmarks would be destroyed, killing thousands and affecting everyone in the country?

The immediate emergency responses to those events and the subsequent incidents related to intentional anthrax exposure have made us aware that we are not immune from terrorist attack on our home soil. It is now the time to move from the initial stages of shock and disbelief to address prevention and preparation for any future attacks. Nurses are in a formidable position to rally to the challenge and assume leadership in the control of our destiny.

This article will define terrorism, provide a brief history, identify current threats, and provide action steps that nurses everywhere can employ to improve our homeland defense, especially against bioterrorism.

Terrorism Defined

Terrorism refers to the use of agents to create fear and destroy public confidence in a government. Terrorism is also used to bring publicity to a cause. Given these goals, terrorists use violence or the threat of violence to bring about physical harm or death or great psychological trauma. Terrorism is a crime. Thus, criminal investigative procedures and chain of evidence responses must be considered as components of emergency planning and implementation.

History has shown that terrorists have the motivation to bring about great distress. Their motivation may not be based on the same moral or ethical framework that most Americans possess, and their motivation may be difficult for many to understand.

Terrorists possess the ability to implement their plans. While terrorists may use numerous strategies to keep their victims off guard and disoriented, many of the methods of operation remain the same. Adequate financial backing provides the economic resources for project implementation.

Terrorists also possess the technical expertise to implement their attacks. While some strategies are very complex, requiring specialized knowledge, many are low tech, requiring simple skills and procedures.

History of Terrorism

Terrorism is not new. Some of the earliest documented terrorist attacks occurred in 1346 in the Ukraine. At that time, bodies of soldiers who died of the plague were thrown over the wall of the city to contaminate enemy forces. In 1763, the British gave smallpox-contaminated blankets to the Native Americans. In 1916-1918, Germans infected livestock and animal feed with anthrax. In 1984, a religious group in The Dalles, Oregon contaminated local salad bars as a way to influence a local election. In 1996, a Dallas, Texas hospital worker offered Shigella-contaminated pastries to her co-workers. This is just a sample of the variety of terrorist activities that have taken place throughout history.

Current Threats

Anyone watching the broadcast media over the past few months knows the list of current threats is almost endless: aircraft being used as missiles; crop dusters being used to spread chemical or biological agents; food contamination; disruption of telecommunication, computer and energy systems; and destruction of highways, tunnels, airports, bridges or monuments of national significance.

While these strategies pose credible threats, there is an even greater concern regarding nuclear, biological, and chemical devices. Of particular relevancy for nurses is the use of biological agents in terrorism. Biological agents are readily available and most are capable of reproduction. Dispersal agents are attainable. Vulnerable civilian populations exist often with no or limited vaccine available. These concerns are magnified by the fact that most illnesses caused by potential biological agents are difficult to detect in the early stages. High morbidity is probable once symptoms occur. Large numbers of deaths totaling in the thousands or tens of thousands are theoretically possible based on historical epidemics.

The effects of a mass biological exposure may not be seen for days after an agent is disseminated. Often, community-wide indicators or disease patterns are the first sign. Early indicators are as follows: 1) rapidly increasing disease incidence in a normally healthy population, especially febrile illness with sepsis, pneumonia, respiratory failure, rash, or flaccid paralysis; 2) unusual age distribution of common diseases (for example, chickenpox among adult patients); 3) unusual incidence of patients with fever, respiratory, or GI symptoms (especially if rapidly fatal); and 4) clusters of ill persons from a single locale or event (Morbidity and Mortality Reports, 2001).

There are numerous biological agents that are viewed as credible threats. Four are most often cited. Anthrax has already been seen as a bioterrorist agent. Other likely agents are smallpox, plague, and botulism. A description of these agents and the diseases they produce is outside the scope of this article. However, the Internet is an excellent source of information on the rapidly evolving conditions. Excellent reference sites include:

Daily updates and topical Web casts: Centers for Disease Control at http://www.bt.cdc.gov
General information: Johns Hopkins Center for Civilian Biodefense Studies at http://www.hopkins-biodefense.org/index.html
Free access to the American Medical Association’s recent articles on anthrax, smallpox, plague and botulism can be found at http://www.ama-assn.org These references are consensus articles that provide excellent overviews of each biological agent.

What Can Nurses Do Now?

The country’s 2.7 million nurses are ideally positioned for leadership in the war against bioterrorism. There are several action steps nurses can take today.

Dialogue with local, state, and national officials regarding current preparation.
Acquaint legislators and congressional members about the need to fund proposals to rebuild the public health infrastructure and strengthen communications among public health officials, emergency planners, first responders, and emergency department personnel.
Become familiar with your employer’s plan for dealing with the consequences of weapons of mass destruction (WMD) attack. Many institutions already have a disaster plan and training for Critical Incident Response in place. Use this as a base. Add components related to surge enhancement, decontamination, and specific responses to nuclear, chemical, and biological events. Encourage your employer to consider topics such as personal protection equipment, emergency pharmaceutical supplies, security, and mock drills.
Prepare yourself to identify clinical signs and symptoms of possible biological attack as relevant to your particular area of practice. Indeed, because of the large workforce, geographical distribution, and presence in a variety of settings, nurses may be a “new” type of first responder. In this role, nurses will identify unusual disease patterns in primary care practices, doctor’s offices, school settings, or home visits to at-risk patients. Nurses will often be the first to alert the public health system to examine community disease surveillance data for abnormalities.
Prepare yourself for a role in case of a major bioterrorist event. Thousands of healthcare professionals flocked to New York and Washington on September 11. Many were well-intentioned but inadequately prepared in terms of knowledge or equipment. Most did not have the proper credentials or linkages with existing emergency response teams. As a result, their efforts were not maximized. At times, their presence even impeded the work of others already on the scene. Experience has shown us that the best way to assist is to be linked into an emergency preparedness plan before the incident occurs. This preplanning will assure that you have been adequately trained, have the necessary personal protection equipment, and can be deployed in an organized fashion.
Commit to being a role model. Use your status as nurse to inform others in your community. Knowledge and preparation are keys to avoiding public anxiety or panic. Serving as a calm, knowledgeable resource in the time after an incident can also do much to reduce panic and post-traumatic stress.
Promote family disaster planning. In the 1950s and 1960s there was an emphasis on bomb shelters and emergency provisions. That was also the time of courses in home nursing of family members. Much of family disaster planning has been lost over time. While today inhabitants of hurricane-prone areas are still urged to prepare a “safe room” as a shelter and stock it with emergency supplies, many give thought only to a few backup batteries and a radio. Yet, the first responders in major natural disasters are neighbors helping neighbors. Nurses can play a key role in reviving home nursing education and promoting family emergency planning. This information can be invaluable in response to natural disasters as well as terrorist attacks. Information on a family disaster plan can be found at the Federal Emergency Management Agency site at http://www.fema.gov/library/yfdp.pdf
Promote increased educational preparation for nurses. Communicable disease, epidemiology, and responses to mass casualty events are rarely found in formal nursing curricula or in continuing education programs today. Yet this basic information is critical for adequate preparation for large-scale terrorist incidents. The Office of Emergency Preparedness has assumed national leadership in promoting enhanced nursing preparation in the area of weapons of mass destruction. Yet much remains to be done.

In summary, the threat of terrorism is real. Nurses are uniquely positioned to assume leadership in local, state, and national responses. It is up to each nurse to assume responsibility for expanding individual professional practice to encompass terrorist attacks.

Dr. Mary Theresa Urbano, PhD, RN, is the Associate Dean for Lifelong Learning at the Vanderbilt University School of Nursing. She has more than 30 years of administrative, clinical, and teaching experiences in nursing. Her master’s and doctoral research focused on continuing education in nursing, and she has received millions of dollars in external grants to fund continuing education programs.

Bibliography

Indicators of Mass Biological Attack. Morbidity and Mortality Weekly Reports (October 19, 2001). http://www.cdc.gov