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METROPOLITAN MEDICAL STRIKE TEAM

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					                                                                        City of Seattle
                                                       Seattle Fire Department (SFD)
                                           Metropolitan Medical Strike Team (MMST)




                                 PREFACE
      The MMST Plans Section will complete the annual update of this plan. It will be
      reviewed annually by the team members for revisions.


      The City of Seattle‘s Department of Emergency Management and the Washington
      State Department of Health, Risk and Emergency Manager have reviewed this
      plan to ensure its compliance with City and State disaster plans.


      The Seattle MMST can be requested regionally as a part of those disaster plans.




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                                                                       City of Seattle
                                                      Seattle Fire Department (SFD)
                                          Metropolitan Medical Strike Team (MMST)
                     METROPOLITAN MEDICAL S TRIKE TEAM

                          OPERATIONAL S YSTEM DESCRIPTION


                                  TABLE OF CONTENTS


Introduction   Health and Medical Services Response to Nuclear/Biological/Chemical
               (NBC) Terrorism

Section 1      Metropolitan Medical Strike Team (MMST)

Section 2      MMST System

Section 3      Team Operations and Field Operations Guide

Section 4      Training Requirements

Section 5      Health and Medical Services

Section 6      Law Enforcement Function

Section 7      Public Information Media Relations

Section 8      Equipment Cache Requirements

Section 9      Communications Group

Section 10     Pharmaceutical Support

Section 11     Recommended Medical Surveillance Guideline

               List of Acronyms

               Glossary

               References




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                                                                        City of Seattle
                                                       Seattle Fire Department (SFD)
                                           Metropolitan Medical Strike Team (MMST)

                                 INTRODUCTION

               HEALTH AND MEDICAL SERVICES RESPONSE
                                         TO
           NUCLEAR/BIOLOGICAL/CHEMICAL (NBC) TERRORISM


A.    OVERVIEW

      The U.S. Department of Health and Human Services (USPHS), in its role as the
      nation‘s health department, is implementing a systems approach for health and
      medical services response to acts of domestic terrorism involving weapons of
      mass destruction (WMD).

      The USPHS strategic national plan concept has two major tenets: first, to assist
      State and local governments and key private sector assets to gain the additional
      necessary capability to effectively and appropriately initially respond in a
      coordinated manner to a local nuclear, biological, or chemical (NBC) terrorist
      incident; and, second, to significantly improve Federal capability and capacity to
      rapidly augment State and local governments in responding to a major terrorist
      incident.

      Building enhanced State and local capability is centered on the implementation of
      the Metropolitan Medical Strike Team (MMST) system development in the most
      populous metropolitan areas of the United States.

B.    BACKGROUND

      Recent events, such as the World Trade Center and Oklahoma City bombings,
      should be a wake-up call to all personnel working in the public safety arena. The
      idea that ‗‗it can‘t happen here‘‘ is at best a dangerous assumption. The use of
      WMD is no longer relegated to use by nation states during war.

      The February 26, 1993, bombing of the New York World Trade Center killed six
      persons and more than 1,000 people were injured, most due to smoke inhalation.

      Although it was never confirmed that they actually used cyanide in the World
      Trade case, the presiding judge at the defendants‘ sentencing hearing believed
      their intention was to use cyanide with the explosive.




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                                                                        City of Seattle
                                                       Seattle Fire Department (SFD)
                                         Metropolitan Medical Strike Team (MMST)
      More than 50,000 people were believed to be in the 110-story building at the time
      of the explosion. One can only imagine what would have happened if a chemical
      attack had been successful.

      In short, the threat to the public, and to public safety agencies responding to
      incidents involving NBC materials, is very real. It is no longer a question of ‗‗if it
      happens,‘‘ since it already has. The real question is when and where the next
      incident will occur.


C.    NUCLEAR MATERIALS

      The most likely scenario facing public safety agencies would be an accident
      involving the transportation of nuclear materials within their jurisdictions. While
      a nuclear power plant may not be next door, materials used to operate that plant
      are transported throughout the United States. For the most part, such incidents
      would be considered a HAZMAT issue and dealt with on that basis by first
      responders.

      Radiation is defined as high-energy particles or gamma rays that are emitted by an
      atom as the substance undergoes radioactive decay, which is the process in which
      a radioactive nucleus emits radiation and changes to a different isotope or
      element. The types of radiation are in the following forms of energetic particles:

              Alpha particles
              Beta particles
              Photons (gamma rays and X-rays)
              Neutrons

      Particles lose their energy by depositing it in the material they move through,
      whether that material is air, water, people, or lead. Alpha particles deposit all
      their energy in a very short distance; very little protective material is required
      from alpha particles. Beta particles require slightly more shielding; gamma rays
      and X-rays require much more shielding. Neutrons react with matter differently
      than do most other kinds of radiation. They are more easily ‗‗stopped‘‘ by
      materials with low atomic numbers or ‗‗low Z materials‘‘ like carbon, lithium, or
      water.

      The problem with radiation is that it is an invisible hazard. Unless the responding
      public safety agency has radiological detection equipment, or the nuclear material
      at issue is clearly marked and identified, there is a strong chance that the initial
      identification of a radiological or nuclear hazard will go unnoticed. Additionally,
      there is no one piece of equipment available on the market to meet all detection
      requirements; however, there are separate detectors for each type of radiation. An
      additional concern would be the availability of protective clothing and breathing
      gear, in sufficient quantities, to protect first responders.


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                                                                          City of Seattle
                                                         Seattle Fire Department (SFD)
                                           Metropolitan Medical Strike Team (MMST)
      Radiation sickness is similar to any other illness in the body. The ‗‗disease‘‘ is
      just radiation. It should be noted that individuals who have been properly
      decontaminated and are suffering from radiation injuries are NOT radioactive!!

D.           BIOLOGICAL AGENTS

      Once the subject of movies like Outbreak or The Andromeda Strain, the use of
      biological agents is the oldest of the NBC triad. Biological agents are more
      deadly than chemical agents and occur in nature as well as being developed.
      Large numbers of naturally occurring poisons have also been examined to
      determine their value as chemical warfare agents; these include capsaicin (an
      extract of cayenne pepper and paprika), ricin (a toxic substance found in the
      castor bean), and saxitoxin (a toxic substance secreted by certain shellfish). Of
      the many natural toxic materials, none has received more attention than the toxin
      of the common bacterium clostridium botulinum, which is sometimes ingested
      from food that has been improperly canned or preserved. A tiny quantity can
      produce death. Sprayed in the air or introduced into a water system, it might
      prove to be a highly effective agent. Of nuclear, biological and chemical agents,
      biological agents are by far the cheapest to produce.

      Governments have used biological warfare as long as civilization has depended
      on agriculture. Today, various governments continue to research the development
      of poisonous toxins that are far more deadly than chemical warfare agents.

      The most practical method of initiating infection using biological agents is
      through the dispersal of agents as minute, airborne particles (aerosols) where
      finely divided particles of liquid or solid suspended in a gas are sprayed over a
      target where the particles may be inhaled. An aerosol may be effective for some
      time after delivery, since it will be deposited on clothing, equipment, and soil.
      When the clothing is used later, or dust is stirred up, responding personnel may
      be subject to a ‘‘secondary’’ dispersal.

      Biological agents may be able to use portals of entry into the body other than the
      respiratory tract. Individuals may be infected by ingestion of contaminated food
      and water or even by direct contact with the skin or mucous membranes t hrough
      abraded or broken skin. This makes the use of protective clothing a must, along
      with protection of the respiratory tract through the use of a mask with biological
      filters or SCBA.

      Exposure to biological agents, unlike chemical agents, may not be immediately
      apparent. Casualties may occur minutes, or hours to days or weeks after an
      incident has occurred. There are currently no effective monitoring devices
      available for first responders for use in determining whether they are involved in
      an incident involving biological agents. The precautionary use of the appropriate
      PPE would be prudent given the lack of detection equipment.



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                                                                        City of Seattle
                                                       Seattle Fire Department (SFD)
                                           Metropolitan Medical Strike Team (MMST)
      Some clues may be present that could be indicators that an NBC incident
      involving biological agents has taken place.

              Unusual numbers of sick or dying people and animals are present. For
               example, all the birds that are usually present at outside trash bins are
               dead, there are no insect sounds, etc.

              Reported illness reflects an unusual or impossible agent for the geographic
               area or there is an unusual distribution of the disease (i.e., the casualties
               are aligned with the wind direction outdoors).

              Biological attacks will be different from natural outbreaks of disease, i.e.,
               a steady stream of patients to medical facilities instead of peaks and
               valleys, or the illness may occur in an unusual environment or time of year
               (i.e., cases of anthrax show up where none have occurred before).

      Early warning and rapid identification of biological agents is of primary
      importance. Early warning can sometimes be supplied by intelligence sources,
      but early warning is not usually available. The following are some rules of thumb
      for defense against biological agents.

              Maintain current threat information. Once a threat is known, personnel
               should review information on biological agent capabilities, symptoms, etc.

              Alert all personnel to the possibility of an attack involving biological
               materials based on intelligence information (if any).

              Identify backup supplies of antidotes, etc., and their location.

              Get medical evaluation to identify the biological agent.

                Pending identification of the agent, measures should be taken to
                 prevent epidemics as soon as possible after initial exposure. These
                 measures include isolation, quarantine, and restriction of personnel
                 movement. After identification of the agent, and if it is not capable of
                 producing an epidemic, these restrictive measures can be relaxed. This
                 applies not only to the victims at the incident, but to all first
                 responding personnel as well.

              If the incident involves a few exposed persons, then transportation from
               the scene to a medical facility may be reasonable. The facility to which
               casualties are transported must be alerted, and the facility should be
               capable of isolating the patients when they arrive.

               


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                                                                       City of Seattle
                                                      Seattle Fire Department (SFD)
                                          Metropolitan Medical Strike Team (MMST)
                When large numbers of exposures are involved, a quarantine should be
                 imposed and victims treated on site.

              Depending on identification of the agent, medical treatment in the form of
               antibiotics, antitoxins, or antiviral agents to persons exposed to the
               biological agent should be administered by appropriate medical
               authorities.

              Destroy all exposed food and water. Some biological agents cannot be
               destroyed by normal water purification techniques.

              Collect and destroy all waste products, including human waste products of
               victims and possibly contaminated first responders. This is done to ensure
               that the agents are not spread through normal waste handling procedures.


E.             CHEMICAL AGENTS

      Chemical agents are compounds that, through their chemical properties, produce
      lethal or damaging effects on man.

      Chemical warfare agents designed to incapacitate by entry through the skin are
      probably best exemplified by the well-known mustard gas and Lewisite
      (chlorovinyl dichloroarsine). These agents severely burn or blister the skin and
      may cause permanent damage to the lungs, if inhaled. Mustard gas was especially
      feared during World War I, and large stocks are still held by some countries,
      including the United States. Harassing agents, such as tear gas, have been
      developed to produce a less severe effect.


      The groups of toxic substances receiving the greatest attention are the organ-
      ophosphorous nerve agents. The German product Tabun was only the first in a
      series of these compounds, which now include the U.S. standard nerve agent
      Sarin (methyl- isopropoxy fluoro-phosphine oxide) and the United Soviet Socialist
      Republic‘s (USSR‘s) Soman (methyl pinacolyloxyfluoro phosphine oxide). All
      these nerve agents produce the same basic physiological effect: they act upon
      enzymes at the myoneural (muscle-nerve) junction, causing immediate
      convulsions, paralysis, and death. They are capable of entering the body either
      through the lungs or the skin and are deadly in very small quantities.

      Chemical agents are defined as any chemical substance intended for use in
      military operations to kill, seriously injure, or incapacitate humans because of its
      physiological effects. Chemical agent symbols usually consist of two letters that
      are used as a designation to identify chemical agents (e.g., GA = Tabun) and have
      nothing to do with the chemical formula of the agent. Unlike biological agents,



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                                                                          City of Seattle
                                                        Seattle Fire Department (SFD)
                                           Metropolitan Medical Strike Team (MMST)
      the onset of medical symptoms is measured in minutes to hours instead of days.
      Additionally, easily observed signatures such as colored residue and dead foliage,
      insects, and animals are present.


      PERSISTENCY—An expression of the duration of effectiveness of a chemical
      agent. The level of persistency is used to describe the tactical use of chemical
      agents and should not be used as terms to technically classify the agent:

              Nonpersistent Agents—Remain in the target for a relatively short period
               of time. The hazard, predominately vapor, will exist for minutes or, in
               exceptional cases, hours after dissemination of the agent. As a general
               rule of thumb, nonpersistent agent duration will be less than 12 hours.

              Persistent Agents—Remain in the target area for longer periods of time.
               Hazards from both vapors and liquids may exist for hours, days, or in
               exceptional cases, weeks after dissemination of the agent. As a general
               rule of thumb, persistent agent duration will be greater than 12 hours.

      There are many factors that will affect the persistency of chemical agents.

              Type of Agent—Different agents have various consistencies or viscosities,
               ranging from rubbing alcohol to motor oil, and will evaporate or dissipate
               at approximately the same rate.

              Amount of Agent—Different amounts and dispersal of agents also impact
               the persistency of an agent.

              Terrain—The terrain will also affect the duration of an agent (open area,
               vegetative, urban, soil composition, etc.). For example, terrorist use of a
               chemical agent would be most effective in enclosed spaces such as
               building entrances or underground subway platforms.

              Weather—Wind, temperature, humidity, precipitation—all impact on the
               duration of an agent.

      The following information is provided in order to give a general overview of
      chemical agents.

              NERVE AGENTS—Chemical agents that affect the transmission of nerve
               impulses by reacting with the enzyme cholinesterase, permitting an
               accumulation of acetylcholine and continuous muscle stimulation. The
               muscles tire due to overstimulation and begin to contract. Nerve agents
               are colorless to light-brown liquids, some of which are volatile. Toxic




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                                                                              City of Seattle
                                                             Seattle Fire Department (SFD)
                                               Metropolitan Medical Strike Team (MMST)
               liquids are tasteless. Nerve agents may be absorbed through the skin,
               respiratory tract, gastrointestinal tract, and the eyes; however, significant
               absorption through the skin takes a period of minutes, and prompt medical
               treatment and decontamination are imperative.

              CHOKING AGENTS—Chemical agents that irritate the alveoli in the
               lungs. This irritation causes the alveoli to constantly secrete fluid into the
               lungs. The lungs slowly fill with this fluid (called pulmonary edema), and
               the victim dies from lack of oxygen (also known as dry land drowning).

              BLOOD AGENTS—Chemical agents that act upon the enzyme
               cytochrome oxidase. This allows the red blood cells to acquire oxygen,
               but does not allow them to transfer oxygen to other cells. Body tissue
               decays rapidly due to lack of oxygen and retention of carbon dioxide (first
               the heart and then the brain are affected).

              BLISTER AGENTS—Chemical agents that affect the eyes, respiratory
               tract, and skin, first as a cell irritant and then as a cell poiso n. Blister
               agents initially cause irritation of the eyes (and respiratory tract, if
               inhaled), erythema (reddening of the skin), then blistering or ulceration,
               followed by systemic poisoning. There are three types of blister agents:
               mustards, arsenicals, and urticiants.

              INCAPACITATING AGENTS—Agents that cause physiological or
               mental effects that lead to temporary disability lasting from hours to days
               after exposure to the agent has ceased.

              VOMITING AGENTS—Compounds that cause irritation of the upper
               respiratory tract and involuntary vomiting.

              IRRITANT OR TEAR AGENTS—Compounds that cause a large flow of
               tears and intense (although temporary) eye pain and irritation. The effects
               are immediate but transient.

      Many highly technical defense systems against chemical agents have been
      developed. Protective gas masks combine particulate filters with substances that
      absorb gases and can remove a variety of toxic agents. Other protective devices
      include chemically treated clothing and suits with portable ventilating systems
      and sealed and air-conditioned tanks and personnel carriers. In recent years
      chemical agent detectors have been developed that readily identify whether some
      agents are present.

      The availability of antidotes and training of medical personne l to handle
      casualties are important defensive measures. Most are reasonably effective if




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                                                                          City of Seattle
                                                       Seattle Fire Department (SFD)
                                           Metropolitan Medical Strike Team (MMST)
      some early warning is possible. In the absence of warning, a successful chemical
      attack would have an immediate impact on the jurisdiction of the affected area.

      The possible mixing of chemical agents presents an additional concern to first
      responders in that it will be difficult to identify (by symptoms alone) which type
      of chemical agent is being used.

      Another concern is that without advance warning, first responders may not be
      aware that they are dealing with a chemical incident. As a result, first responders
      may initially become part of the victims in such an incident.

        Some clues may be present that could be indicators that an NBC incident
involving chemical agents has taken place.

              Unusual numbers of dying animals are present. For example, all the birds
               that are usually present at outside trash bins are dead, there are no insect
               sounds, etc., not just an occasional roadkill, but numerous dead animals.

              Lack of insect life. If normal insect activity (ground, air, and/or water) is
               missing, then check the ground, water surface, or shoreline for dead
               insects.

              Numerous individuals are experiencing unexplained water- like blisters,
               wheals (like bee stings), and/or rashes.

              Numerous individuals are exhibiting serious health problems ranging from
               nausea, to disorientation, to difficulty breathing, to convulsions, and to
               death. It is apparent that a mass casualty incident exists.

              There is a definite pattern of casualties (i.e., the casualties are aligned with
               the wind direction outdoors). Casualties are distributed in a pattern that
               may be associated with possible agent dissemination methods (i.e., a lower
               number of ill people working indoors versus outdoors, or o utdoors versus
               indoors).

              Unusual liquid droplets are present. Numerous surfaces exhibit oily
               droplets/film; numerous water surfaces have an oily film. (No recent
               rain.)

      Early warning and rapid identification of chemical agents are of primary
      importance. Early warning can sometimes be supplied by intelligence sources,
      but early warning is not usually available. The following are some rules of thumb
      for defense against chemical agents.




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                                                                           City of Seattle
                                                        Seattle Fire Department (SFD)
                                            Metropolitan Medical Strike Team (MMST)
              Maintain current threat information. Once a threat is known, per sonnel
               should review information on chemical agent capabilities, symptoms, etc.

              Alert all personnel to the possibility of an attack involving chemical
               materials based on intelligence information (if any).

              Identify backup supplies of antidotes, etc., and their locations.

              Take steps to identify the chemical agent used, either through local
               HAZMAT teams or military resources.

      Decontaminate victims prior to transporting them to local medical facilities.

F.    HAZMAT/NBC TERRORIST INCIDENT CONSIDERATIONS

      An NBC terrorist incident is, inherently, a HAZMAT incident. There are,
      however, significant differences between the two types of incident that influence a
      civil jurisdiction‘s response planning, organization, training, equipment,
      operational procedures, and coordination requirements. An NBC terrorist
      incident may be characterized by:

              The use of WMD designed to inflict mass casualties.

              The high lethality of biological or chemical agents.

              The extremely toxic environment resulting from NBC WMD.

              The relative ease and inexpensive manner for NBC WMD production.

              The significant legal implications due to the fact it is a crime scene and
               must be treated appropriately.

              The initial ambiguity in determining what type of NBC weapon or agent is
               involved, or, in the case of biological agents, if a terrorist incident has
               occurred;

              The potential for a combination of weapons/agents each presenting
               different response requirements, i.e., explosives and chemical agents or
               simultaneous explosives, chemical agents, and radioactive material
               dispersal.

              The narrow window-of-response time to administer lifesaving antidotes
               for chemical agents and antibiotics for biological agents.




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                                                                       City of Seattle
                                                     Seattle Fire Department (SFD)
                                        Metropolitan Medical Strike Team (MMST)
              The NEED for immediate medical treatment for mass casualties.

              The NEED for transportation of mass casualties to appropriate medical
               facilities.

              The NEED for immediately available specialized pharmaceuticals.

              The NEED for specialized NBC detection equipment.

              The NEED for a timely, efficient, and effective mass decontamination
               system.

              The NEED for an organized, trained, and equipped health and medical
               services emergency response unit to immediately augment the local
               HAZMAT/EMS response.

              The NEED for precoordination with hospitals and medical treatment
               centers to establish medical treatment protocols, stock appropriate
               pharmaceuticals, and determine treatment procedure requirements; and


   The NEED to accomplish advance planning and coordination to respond to each
   of the NEEDS identified above.




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                                                                                          City of Seattle
                                                                         Seattle Fire Department (SFD)
                                                             Metropolitan Medical Strike Team (MMST)


                    METROPOLITAN MEDICAL STRIKE TEAM

                                             CHAP TER ONE

                                        TABLE OF CONTENTS


PART I                                                                                                                          Page

Metropolitan Medical Strike Teams Mission Statement ........................................................ 1-1
MMST Scope of Operations .................................................................................................1-2
MMST Concept of Operations.................................................................................................1-2
MMST Management Structure ...............................................................................................1-5
MMST Management Roles and Responsibilities ...................................................................1-6
MMST Membership/Organizational Structure .......................................................................1-7
MMST Members Roles and Responsibilities .........................................................................1-7




PART II
MMST Role in Supporting First Responders .........................................................................1-11
MMST Activation ................................................................................................................1-12
MMST Deployment ..............................................................................................................1-13
MMST Predeployment Actions ............................................................................................ 1-17
Cancellation of an MMST Deployment .................................................................................1-17
NBC Agent Detection and Identification ..............................................................................1-18
MMST Extraction and Antidote Administration Activity .....................................................1-19
MMST Triage and Decontamination Activity .......................................................................1-21
MMST Field Casualty Collection Center ..............................................................................1-22
MMST Field Medical Operations (treatment/transportation) ................................................1-23
MMST Pharmaceutical Cache and Concept of Operations ...................................................1-26




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                                                                           City of Seattle
                                                          Seattle Fire Department (SFD)
                                              Metropolitan Medical Strike Team (MMST)




                METROPOLITAN MEDICAL STRIKE TEAM

                                      CHAPTER II
                                   MMST SYSTEM

   INTRODUCTION

   Purpose
           This chapter will:
            Provide an overview of the Seattle MMST System
            Define the critical components of an MMST System
            Describe each critical component as it applies to the City of Seattle
            Describe required actions or remaining gaps for each component



   Overvie w of the Seattle MMST System
           Like it or not, WMD weapons are not limited to the battlefield. When used on a
           city, these weapons can quickly overwhelm a community health care system
           and cause widespread psychological impact on the population. In the last few
           years, civilian experience with WMD events has demonstrated that an effective
           response requires timely, appropriate, and well-coordinated community actions
           beyond most local capabilities. The need to close this gap in community
           preparedness has been the drive for developing a ―Metropolitan Medical Strike
           Team System‖ in Seattle.

           What is Seattle‘s MMST System? Part of the MMST System is a new
           professional/technical strike team that trained, equipped, and is prepared to
           work safely in a nuclear, biological, and chemical environment. The remaining
           parts of the System are enhancements of several existing City response
           agencies, such as; Law Enforcement, HazMat, Fire, EMS, Public Health and
           City hospitals. These agencies alone don‘t have the training, equipment,
           antidotes, or strong interdepartmental linkages necessary for an effective
           response to a NBC incident. All must act together in a coordinated, multi-
           agency response. From the initial 911 call to patient evacuation out of the City,
           the MMST System coordinates scene control, agent identification, victim
           extraction, field treatment and decontamination, patient transportation,
           definitive hospital care and coordination with National Disaster Medical
           System. Each component of the MMST System is an interdependent link that --


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                                                                               City of Seattle
                                                            Seattle Fire Department (SFD)
                                               Metropolitan Medical Strike Team (MMST)
           taken together--forms a ―chain of survival‖ for victims in a WMD event. Each
           link in the chain is one component in a cascading system that coordinates many
           agencies; providers, responders, and resources needed to manage the human
           health consequences of a terrorist incident in Seattle. If any link in the chain is
           weak, survival rates will be reduced.
           To mount an effective WMD response, the City has nurtured and built stronger
           communication linkages between departments, conducted multi-disciplinary
           planning and exercises, developed specialized training, and begun procuring
           needed equipment. To ensure our activities are cost-effective, Seattle has
           focused the MMST System Development on four principal areas:

              Identifying ―components‖ (i.e., Fire, EMS, etc.) in the City that would
               normally respond to WMD event

              Augmenting those ―components‖ to meet the additional demands of a
               WMD event

              Developing new ―component(s)‖ (i.e., Metro Medical Strike Team) that
               would improve our response to a WMD event, and

              Strengthening communication and planning linkages between all the critical
               components

           Today, are all links in Seattle‘s ―chain of survival‖ as strong as they should be?
           No. Is additional funding of critical components needed? Yes. Do current
           public and private funding levels adequately support all the essential links in the
           chain? No. Gaps still remain. Funding for private/public hospitals to prepare
           for a WMD event (e.g., hospital decontamination equipment, hospital PPE, etc.)
           remains weak. Some private health care facilities are struggling to survive,
           facing strong competitive pressures in the marketplace. Because of these
           economic conditions, WMD preparation remains a low priority with many
           hospitals. These political and funding challenges should not discourage or
           dissuade the community from getting prepared but it has prod uced barriers to
           each link in the ―survival chain‖ reaching full potential at the same time.

           Over the last year, WMD awareness has been raised at all levels in the City.
           Strong partnerships have been built that will significantly improve the City‘s
           response to a WMD event. However, wherever the Program Management
           Team‘s influence and authority have been limited, commitment of resources has
           lagged and WMD preparedness has been slower than hoped.

           What has been accomplished in less than one year? Communication and
           planning linkages between City/County departments, State/Federal public
           health, and private industry have significantly improved and public interest and
           commitment have taken a positive turn. The City of Seattle has committed


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                                                                                     City of Seattle
                                                                    Seattle Fire Department (SFD)
                                                       Metropolitan Medical Strike Team (MMST)
                  1000‘s of hours in training, and planning for a WMD event. Tremendous strides
                  have been made at bridging several strong departments (i.e., EMS, Fire,
                  Hospital, Public Health, etc.); into one ―response army‖ --- an MMST Response
                  System. These initial actions make a strong foundation for the MMST System.
                  It has placed the goal of an effective response within grasp, but more training,
                  more equipment, and more planning remain to be done.

                  The remainder of this chapter highlights each of the critical components in the
                  Seattle MMST System, outlining what has been accomplished, what needs to be
                  accomplished, and our plan for closing any preparedness gaps.


MMST Critical Components


          MMST System – Critical Components
           The critical components and systems that make up Seattle‘s MMST System are:
                  1. Metro Medical Strike Team                                MMST SYSTEM

                  2.   Health Care System
                                                                                   MHS         MMST
                  3.   EMS System

                  4.   Mental Health System                              Non-
                                                                                         EOC          Health Care
                                                                       Survivors
                                                                                                        System
                  5.   Disposition of Non-Survivors

                  6.   Emergency Operations Center (EOC)                       Patient                       E
                                                                              Movement                       M
                                                                                                             S
                  7.   Forward Movement of Patients
                                                                                                             S
                                                                                                             y
                                                                                                             s
                                                                                                             t
                                                                                                             e
                                                                                                             m




       11/07/98                                                                                          3
                                                                              City of Seattle
                                                             Seattle Fire Department (SFD)
                                                 Metropolitan Medical Strike Team (MMST)


Critical Component # 1

   Metro Medical Strike Team
           The Metro Medical Strike Team (MMST) is a technical-                           MMST
           professional team that provides on-scene assistance and                        SYSTEM
           telephone consultation to local and regional responders           Patient
                                                                             MHS         MMST
                                                                           Movement
           in the event of a WMD threat. The MMST is a key
           component of the overall MMST System and                                           Health Care
                                                                     Non-
           operates within the City of Seattle‘s Disaster          Survivors         EOC       System
           Management Plan. The organization and concept
           of operations for the MMST is thoroughly
           discussed in Chapter I, Part 1 (see page 1-2). A short            Patient
                                                                              MSH                  E
                                                                           Movement                M
           overview of the MMST capabilities is discussed here.                                    S
           For a more detailed discussion of the actions,                                          S
           operations, and organization of the Metro Medical Strike                                y
           Team, see Chapter I, Part 2 (see page 1-11).                                            s
                                                                                                   t
                                                                                                    e
       To ensure an effective WMD response, the Seattle MMST performs the                           m
       following essential actions:

              Reconnaissance
              Agent identification
              Victim rescue/extraction
              Antidote administration
              Decontamination
              Triage
              Field medical care (Primary Care)
              Preparation for victim transport
              Technical assistance (e.g., HazMat, toxicology, etc).




11/07/98                                                                                        4
                                                                              City of Seattle
                                                             Seattle Fire Department (SFD)
                                                 Metropolitan Medical Strike Team (MMST)
           In addition to the activities listed above, the MMST maintains several linkages
           throughout the MMST System that facilitate communication, patient tracking,
           field care, and patient flow. These linkages are through the following team
           positions: Hospital Liaison, Law Enforcement Liaison, and the MMST Medical
           Director.

Critical Component # 2

   Health Care System                                                    MMST SYSTEM
           The Health Care System within the City of Seattle
           consists of 12 hospitals (1 level-1 and 11 level-2) with           Patient     MMST
           over 3100 beds. Within the immediate King County                 Movement
           area, there are an additional 19 primary care
           hospitals (4900 beds) to support the existing              Non-                     Health Care
           health care system. The cornerstone of the               Survivors         EOC        System
           Seattle/King County Hospital System network is
           the University of Washington Medical
           Center(UWMC). Conducting world-renowned                              MHS                  E
                                                                                                     M
           research, UWMC includes three of the largest area                                         S
           hospitals; University of Washington Hospital, the
                                                                                                     S
           Children’s Orthopedics Hospital, and Harborview Medical                                   y
           Center (Trauma center). These three hospitals support and train all Seattle Fire s
           Department paramedics. This arrangement facilitates the MMST System’s                     t
                                                                                                     e
           need for strong field-hospital communication, standardized treatment protocols, m
           and an effective interaction between the EMS and Hospital Systems.

           Normally, patient entry into the Hospital System is by EMS transport or through
           self-referral (walk in, private transport, etc.). In a WMD event, patients
           transported to the hospital by Seattle EMS will have been decontaminated and
           directed to definitive care through Hospital Control.

           However, WMD events which occurred in Oklahoma City and Tokyo suggest
           that as many as 80% of affected victims may circumvent our EMS system and
           self-refer themselves to a medical facility. Therefore, a W MD incident has a
           high potential to disrupt the community Health Care System.

           To ensure an effective WMD response, the Seattle Health Care System
           must successfully address the following key areas:

              Hospital control
              Hospital decontamination/cross contamination
              Provider WMD training
              Hospital security/crowd control
              Hospital supply
              Public health/Patient tracking




11/07/98                                                                                          5
                                                                                City of Seattle
                                                               Seattle Fire Department (SFD)
                                                   Metropolitan Medical Strike Team (MMST)
        Hospital Control
                    Without proper casualty distribution, self-referred victims may
                    overwhelm the nearest hospitals while nearby facilities remain available
                    and underutilized. The City of Seattle hospital network distributes
                    casualties through one communication central point called ―Hospital
                    Control.‖ Based out of Harborview Medical Center, Hospital Control
                    serves as the ―disaster coordination hospital,‖ redirecting EMS
                    transportation and medical resources to ensure continuity of emergency
                    care.

                    During periods of peak usage (i.e., disaster), Hospital Control collects
                    information from the area hospitals regarding their capacities and
                    capabilities. This system promotes inter-hospital communication ---
                    reducing hospital peak usage overloads, while ensuring patients are
                    directed to the most appropriate, timely care.

                    Communication between area hospitals is maintained using a radio
                    system (Medcom). This system is exercised daily, with each hospital
                    reporting bed availability and critical care status. Alternate back- up
                    communication networks are in place and practiced (cell phones, faxes,
                    pagers, and runners). These back- up systems ensure continued hospital
                    communication and the exchange of critical information (e.g., patient
                    loads, agent identification, toxicity profiles, treatment modalities, etc.),
                    should the primary communication infrastructure collapse.


Remaining Gaps in Hospital Control
                            None. The system is well designed and needs no augmentation at
                            this time. The Hospital Control Physician collects information on
                            area hospital capacity and casualties from the scene then uses this
                            information to direct ambulances to a destination for the most
                            appropriate care and timely care.

        Hospital Decontamination / Cross Contamination
                    Victims who circumvent decontamination at the incident site, risk
                    contaminating valuable medical resources (e.g., medical facilities and
                    staff). Contamination of hospital facility or staff will reduce critical
                    health resources and expand the WMD incident scene and hot zone.

                    1.1        Remaining Gaps in Decontamination
                            Generally, health care facilities in the City of Seattle have limited
                            capabilities to perform decontamination (1-2 patients). Many of
                            these are dedicated indoor showers with no water capture or
                            separate HVAC system. This capacity not robust enough to


     11/07/98                                                                                       6
                                                                                City of Seattle
                                                               Seattle Fire Department (SFD)
                                                  Metropolitan Medical Strike Team (MMST)
                          provide effective hospital decontamination for large numbers of
                          patients. Few hospitals in our area have shown the will/motivation
                          to plan, budget, or allocate resources that would provide 1) robust
                          patient decontamination, 2) provider WMD training or, 3)
                          appropriate PPE to support a WMD event.

Plans for Improve ment for Decontamination
                          Our long-range plans to correct these gap are:

                             Continue to educate and inform the medical community
                             Promote and participate in appropriate hospital planning
                             Partnership with Washington State Hospital Association to
                              move area hospitals toward development of a greater capacity
                              at outside triage and decontamination.
                             As an interim step, the Seattle Fire Department has trained and
                              is capable of establishing decontamination alleys outside of
                              hospitals. Consideration is being given to how the SFD might
                              provide gross decontamination support to critical hospital
                              facilities without negatively impacting other areas of the
                              response.


        Health Care Provider Experience/Training
                    Health care providers who are untrained or inexperienced in WMD
                    patient recognition, treatment, management or use of PPE will reduce
                    survival of WMD victims and increase health provider injuries from
                    cross-contamination.

                    News events, participation in area conferences, and personal contacts
                    made by members of the MMST and MMST Medical Director over the
                    last year have significantly raised WMD awareness levels among Seattle
                    health care professionals and facilities. Over 2,400 fire, police, and
                    health care professionals have completed WMD Training.

                    1.2       Remaining Gaps in Health Care Provider Training
                          Area hospitals and health care providers have had limited
                          experience with WMD patients. While training classes have been
                          highly successful with non- hospital based care providers
                          (EMS/Paramedic), physician attendance has generally been
                          disappointing.

Plans for Improve ment of Health Care Provider Training
                              Members of the Project Management Team, in collaboration
                              with the Washington Hospital Association are identifying


     11/07/98                                                                                7
                                                                            City of Seattle
                                                          Seattle Fire Department (SFD)
                                            Metropolitan Medical Strike Team (MMST)
                          ways to better influence area hospitals and hospital-based
                          physicians to the importance of WMD training.
                         As an interim step, WMD treatment protocols have been
                          approved and distributed to all area hospitals to provide
                          guidance to treating physicians who have not yet completed
                          WMD training.

   Hospital Security - Crowd Control
               Site security is directly related to site safety. Fear, anxiety, and large
               crowds (i.e., patients, media, family, etc.) may overpower established
               hospital security procedures. Keeping unauthorized persons out of the
               treatment area will improve rescue efforts by; decreasing congestion,
               reducing patient looting, and minimizing injuries from cross-
               contamination. Lack of preplanning for victim‘s family members,
               mishandling of ambulatory contaminated crowds, or failure to control
               media convergence will reduce the hospital‘s effectiveness and may
               extend hazardous contamination into the hospital.

              1.3         Remaining Gaps in Hospital Security
                      It is not clear how many area hospitals have effective lock down
                      policies, traffic control procedures, or media plans. General
                      consensus is that hospital security has been given very little
                      attention.

              Plans for Improve ment in Hospital Security
                         To better define the problem, Region X Emergency
                          Coordinator, US Public Health Service, Office of Emergency
                          Preparedness is conducting a telephone survey of all area
                          hospitals. Information from this survey will be used to develop
                          a better understanding of the gap in preparedness and assist us
                          in developing possible solutions.
                         As an interim step, we will work with the Area FCC
                          Coordinator to ensure these issues are addressed in the annual
                          NDMS hospital exercise in March, 1999.

   Hospital Supply
               Hospitals are the first fortified defense for patients in a
               biological/chemical attack. As victims are moved to a hospital, critical
               medical resources such as pharmaceuticals (antidotes/antibiotics),
               specialized equipment (ventilators), and physicians will quickly be
               exhausted. Failure to address these supply limitations will increase
               victim morbidity and mortality.



11/07/98                                                                                    8
                                                                            City of Seattle
                                                           Seattle Fire Department (SFD)
                                               Metropolitan Medical Strike Team (MMST)

                    1.4   Remaining Gaps in Hospital Supply
                                 Limited Pharmaceutical Supply
                              Each of Seattle‘s hospitals have limited supplies of antidotes
                              (~100 –150 doses of atropine) and antibiotics that could be
                              used in a WMD event. In a large-scale event, these supplies
                              would not sustain the hospitals for a 24- hour period.

                                  Ventilators
                              The 30 hospitals within Seattle/King County maintain
                              approximately 275 in- house ventilators. Most of these
                              ventilators are consolidated in the 4-5 largest hospitals. At
                              any one time ~50% of these ventilators are in use. During
                              periods of high ventilator demand, some hospitals have
                              informal loan agreements to share ventilators and supplies.
                              An alternate source for ventilator support is through a national
                              rental company (MedicPRN 800-222-4776). They maintain
                              40 ventilators in Seattle, with an additional 3,000 ventilators
                              warehoused in California. Turn-around time for these
                              warehoused ventilators is approximately 24 hours. There is an
                              additional supply of ventilators available through three home
                              health care agencies in the city.

Plans for improvement of Hospital Supply
        Limited Pharmaceutical Supply.
                             Area hospitals have been slow to adopt the value of an in-
                                 house WMD pharmaceutical cache. It is anticipate, as
                                 greater numbers of hospital administrators and physicians
                                 are WMD-educated, funding for in- house drug caches
                                 may increase.
                             As an interim step, the MMST has developed policies,
                                 procedures, and priorities to guide transfer of unused
                                 MMST drugs stores to depleted health care facilities. In
                                 addition, we have identified several alternative
                                 distribution sources to procure nerve agent antidote
                                 (~4000 doses) and antibiotics within one hour of Seattle.
                                 The MMST Workgroup will continue to investigate
                                 ancillary networks (veterinarian, military, and
                                 commercial vendors) to augment available hospital
                                 supplies.




     11/07/98                                                                                  9
                                                                            City of Seattle
                                                           Seattle Fire Department (SFD)
                                               Metropolitan Medical Strike Team (MMST)

   Ventilators
                                There are over 300 ventilators in Seattle with a large
                                 ventilator pool in California. No additional action is
                                 needed at this time.

   Public Health / Patient Tracking
                  Local health departments are charged with preventing the spread of
                  communicable diseases in the community.

                  Within Seattle, detection of a biological agent attack would most likely
                  occur based on shifts in morbidity and mortality patterns, first identified
                  by local health care providers (e.g., primary care, infectious disease,
                  emergency medicine, etc.). Appropriate surveillance and rapid
                  physician reporting are critical to the process of identifying exposures,
                  particularly common-source exposures, and implementing interventions
                  to reduce or eliminate infection.

                  As far as patient tracking goes, the demands for insurance
                  reimbursement have caused health care facilities to develop
                  sophisticated patient tracking systems. However, there is no integrated
                  tracking system that has been universally adapted to a WMD event. A
                  tracking system that will track a victim from initial triage/treatment,
                  through the EMS system, continuing throughout admission to a local
                  hospital and, finally into forward movement by NDMS.

            1.5 Remaining Gaps in Public Health/Patient Tracking
   Mass Casualty Incident Plan (MCI)
                        An MCI plan has been adopted and agreements are in-place
                        between the hospitals to control patient flow, redistribute
                        patients to the most appropriate facilities for definitive care,
                        and provide for disposition of non-survivors. While the plan is
                        comprehensive, some gaps remain in citywide planning for a
                        biological event. The MCI plan fails to address contagious
                        infections, quarantine issues, and mass vaccination or drug
                        distribution. The MCI plan will be updated in 1999.

   Mass Vaccination/Prophylaxis
                       Seattle/King County Department of Health, Prevention
                       Division, has the responsibility for routine and emergency
                       immunization programs. Sites for vaccinations are situation-
                       dependent (public health centers, schools, etc.) and would be
                       determined by the scope and magnitude of the infection.
                       Emergency vaccinations would be provided at the ten (10)



11/07/98                                                                                    10
                                                                                   City of Seattle
                                                                  Seattle Fire Department (SFD)
                                                      Metropolitan Medical Strike Team (MMST)
                                   County Public Health Centers, then expanded to area satellite
                                   clinics, and then community shelters.

        Community Surveillance
                            Community Surveillance for communicable disease is the
                            responsibility of Seattle/King County Department of Health.
                            Communicable diseases are monitored using a duel
                            physician/laboratory reporting system. Physician/laboratories
                            are legally mandated to report some biological WMD agents
                            (anthrax, botulism, brucellosis, and cholera) within two days.
                            Other biological WMD are not reportable. One-day reporting
                            requirements are also in place for case clusters and unusual
                            communicable diseases.

Plans for Improve ment in Public Health/Patient Tracking
                                  Members of the MMST have met with the Department of
                                  Health, Division of Epidemiology to discuss community
                                  surveillance, quarantine, and mass prophylaxis issues. Future
                                  meetings have been planned to clarify which data elements
                                  (e.g., EMS runs, daily mortality counts, or trends) could be
                                  used as ―triggers‖ for the early recognition of a WMD
                                  biological event. The goal is to develop a sentinel system that
                                  would effectively detect and report disease clusters, unusual or
                                  heavy usage patterns, or unanticipated deaths.

                                  The County Disaster/MCI plan will be updated in 1999. The
                                  goal is to raise awareness of WMD events with City planners
                                  and integrate appropriate WMD contingencies as plans are
                                  updated,


     Critical Component # 3

         B. EMS System                                                                MMST
              SYSTEM
                The next critical link in our MMST system is the EMS                Patient     MMST
                                                                                  Transport
                transportation system. The Seattle/King County
                emergency medical system is a regional partnership                                      Hospital
                                                                            Non-
                of 35 fire departments, five paramedic providers,                           EOC         System
                                                                          Survivors
                cities, the county, the University of Washington,
                Airlift Northwest, and private ambulance
                companies. As a direct result of this integrated                     MHS                    E
                                                                                                            M
                partnership, Seattle/King County‘s emergency medical                                        S
                system maintains a better survival rate for out-of-hospital
                                                                                                            S
                heart attacks than anywhere in the United States.                                           y
                                                                                                            s
                                                                                                            t
                                                                                                            e
                                                                                                            m
     11/07/98                                                                                      11
                                                                                              City of Seattle
                                                                             Seattle Fire Department (SFD)
                                                               Metropolitan Medical Strike Team (MMST)
                              Paramedics trained by Harborview Medical Center operate from five paramedic
                              provider agencies around the county – Seattle Fire Department, Shoreline Fire
                              Department, Evergreen Medic One, Bellevue Medic One, and King County
                              Medic One.

                          To ensure an effective WMD response, the Seattle EMS System must
                          successfully address the following key areas:

                                 WMD Training /Advance life support

                                 Antidote administration

                                 Safe, fast transportation

                                 Patient tracking

                                  1. WMD Training / Advance Life Support
                                     As part of the patient transportation plan, the first line of emergency
                                     transportation of victims to definitive care will be the Seattle Fire
                                     Department, Emergency Medical Services (EMS). The Seattle Fire
                                     Department, EMS Division, provides BLS/ALS transport. Seattle Fire
                                     Paramedics have over 2000 hours of training under the direction of the
                                     Hospital Control Physician. All personnel have completed WMD
                                     training and refresher training has been integrated into the EMS
                                     training schedule.

aps in WMD Training/Advance Life Support
                                    None. There is no additional augmentation necessary at this
                                    time. Staff is well trained and the System is a nationally
                                    recognized first responder program.

                     Antidote Administration
                                  EMS personnel have been trained in antidote administration and the
                                  EMS Medical Director has approved WMD treatment protocols. Some
                                  transport vehicles have begun stocking a limited number of WMD
                                  pharmaceutical (Marc-1 auto- injectors and diazepam). A MMST
                                  pharmaceutical plan has been developed. This drug cache will augment
                                  existing EMS antidote supplies.




                   11/07/98                                                                                12
                                                                                                  City of Seattle
                                                                                 Seattle Fire Department (SFD)
                                                                     Metropolitan Medical Strike Team (MMST)

aps in Antidote Administration
                                               Pharmaceutical cache remains to be approved and procured.

                      Safe, Fast Trans portation
                                    Seattle emergency medical system is nationally recognized as one of
                                    the best in the United States. It maintains a better survival rate for out-
                                    of- hospital heart attacks then anywhere in the United States and has an
                                    under four- minute response time anywhere in the City of Seattle.

aps in Fast Transport
                                               There is no need for changes in this system. The response
                                               times are efficient.

                                        Patient Tracking
                                        A Mass Casualty Incident Plan has been adopted and exercised by the
                                        City and area hospitals to address standardized triage, patient flow,
                                        patient tracking, and safe transportation of patients to definitive care
                                        facilities. The current tracking system uses a sequential numbering
                                        system, via an ID tracking number written in indelible ink pen on the
                                        patent‘s forehead.

emaining Gaps / Plans for Improve ment in Patient Tracking
                                       Patient tracking tags are being designed to better maintain
                                       information on patient location and routing. An NDMS exercise
                                       planned for April 1999 will focus on improving patient tracking
                                       between EMS/Hospital/NDMS.


                    Critical Component # 4

                        C. Mental Health Care System                                         MMST SYSTEM
                               Disasters often cause behavioral changes in adults and
                               children. Many react with fear and show signs of anxiety         Patient    MMST
                               about recurrence after a WMD event. Some will                    Movem
                                                                                                   ent
                               experience psychosomatic illnesses. During the             Non-                  Hospital
                               recovery, most victims will display periods of anger,     Survivor       EOC     System
                                                                                            s
                               mood swings, suspicion, irritability, and/or apathy.
                               Increased levels of stress can worsen pre-existing                 MHS                 E
                               physical problems such as heart trouble, diabetes, and                                 M
                                                                                                                      S
                               ulcers. In addition, victims and responders may develop
                               decrements in performance because of inadequate rest, stress, or concerns about
                               family and friends. Long after the disaster has resolved, both responders and
                               victims may feel haunted by visual memories of the event. For this reason,
                               ensuring victims and responders are provided early critical incident stress



                    11/07/98                                                                                       13
                                                                             City of Seattle
                                                           Seattle Fire Department (SFD)
                                             Metropolitan Medical Strike Team (MMST)
           debriefing and long-term psychological support is crucial to the mental health of
           citizens in the community.

           To ensure an effective WMD response, the Seattle Mental Health Services
           must successfully provide:

                Early critical incident stress debriefing
                For first responders
                For victims, families, and the community

                Long term psychological support



                2. Early Critical Incident Stress Debriefing
                       First Responders
                        A joint Critical Incident Stress Management Team (CISM) exists for
                        Police and Fire responders. It is staffed with police psychologists
                        and a cadre of trained Police and Fire personnel. The incident
                        commander, 911- dispatch center, or any ranking officer can request
                        this team.

                        Should additional services be needed, the Emergency Medical
                        Services Division of the Seattle/King County Health Department
                        will coordinate with the Seattle Police Department (SPD), Seattle
                        Fire Department (SFD), and the Washington CISM Net to provide
                        additional counselors from across the State of Washington.

                       Victims, Families, and Community
                        In a disaster, Mental Health Services are requested through the City
                        of Seattle-EOC ESF-8 Coordinator, through the Seattle/King County
                        Department of Human Services, Mental Health Division, and the
                        American Red Cross (ARC).

                        The Mental Health Division is responsible for providing mental
                        health crisis response, involuntary detention services, and outpatient
                        mental health services for persons who suffer from reactions to the
                        disaster.

                        The American Red Cross will provide disaster mental health services
                        to citizens as outlined in ARC Disaster Services Regulations and
                        Procedures, and is dependent on volunteer staffing allowances.




11/07/98                                                                                     14
                                                                             City of Seattle
                                                            Seattle Fire Department (SFD)
                                                Metropolitan Medical Strike Team (MMST)

               2.6 Remaining Gaps/Plans for Improve ment in MHS
                            Responder Mental Health Services. No additional action is
                             needed. The mental health services available to first
                             responders are comprehensive, well designed, easily
                             accessible, and effective.

                            Victims, Families, and Communities. System is generally
                             adequate. Long term mental health services can be delivered at
                             several neighborhood clinics and emergency services could be
                             provided onsite or in treatment facilities. The Seattle/King
                             County Department of Health, Division of Mental Health is
                             meeting to improve the existing response plans related to
                             victim and community intervention.


                             Division of Mental Health personnel has not been trained in
                             WMD awareness. Members of the Program Management
                             Team will discuss the need for the Department of Health to
                             develop a training plan and offer appropriate assistance with
                             training materials and expertise.


Critical Component # 5

    D. Disposition of the Non Survivors                                         MMST
           SYSTEM
           In Seattle, the Medical Examiner's Office (ME) is a unit of
           the Prevention Division of the Seattle/King County
                                                                               Patient         MMST
           Department of Public Health. The Medical Examiner‘s               Movement
           Office has five autopsy specialists and eleven
           investigators. Their office is located at Harborview          Non-                         Hospital
                                                                                         EOC          System
           Medical Center (which serves as Hospital Control in         Survivors
           a WMD event). Causes of death, which come under
           the jurisdiction of the Medical Examiner‘s Office,                                             E
                                                                                 MHS
           include:                                                                                       M
                                                                                                          S

              Unknown or obscure causes                                                                  S
                                                                                                          y
              Deaths caused by any violence                                                              s
              Deaths from a contagious disease                                                           t
                                                                                                          e
                                                                                                          m
           In the field, the Medical Examiner works in coordination with law enforcement
           and is integrated into the on-site Incident Command System.




11/07/98                                                                                         15
                                                                                City of Seattle
                                                              Seattle Fire Department (SFD)
                                                Metropolitan Medical Strike Team (MMST)
           Mass handling of the dead creates unique problems. In a WMD event,
           contamination of the body and personal effects may make routine handling
           impossible. Events of this nature are national in scope frequently generate a
           deluge of queries from concerned relatives, politicians, and media about the
           non-survivors. Collecting information for these queries can be more different
           than in routine fatalities. Plans should address the need for an information
           officer………….

           In a WMD disaster, special materials may be needed for the recovery,
           identification, and care of fatalities. For example, special markers may be
           needed to indicate where the bodies were found, photographs taken before
           bodies are moved, special body pouches or other containers may be required,
           and exceptional provisions (e.g., refrigeration trucks) may be needed to store
           large numbers of bodies. This all has to happen in a manner that is culturally
           sensitive and respectful.

           To support an effective medical response to a WMD event, several areas
           need to be address by the Medical Examiner’s Office. These areas include:

       Mass fatality management
       WMD training/experiences.
       Decontamination policy/procedures
       Personal Protective Equipment (PPE)
       Evidence collection/preservation

      In an NBC mass fatality incident, the ME‘s team is faced with the enormous
      challenge of establishing temporary morgue site(s) in or near contaminated
      environment. For this reason, it is anticipated the ME will require immediate
      State or Federal assistance (i.e., National Guard, DoD Decontamination Tea ms,
      DMORT, DMAT, etc.)




11/07/98                                                                                    16
                                                                         City of Seattle
                                                        Seattle Fire Department (SFD)
                                            Metropolitan Medical Strike Team (MMST)

       2. Mass Fatality Plan (MFP)
Remaining Gaps
                  A mass fatality management plan has been written and is currently
                  being revised to address disposition of non-survivors in a WMD
                  event. Items that have or will be addressed are:
                   Establishing a control element to coordinate ongoing activities
                      and release information updates.
                   Securing the area and limiting access to nonessential personnel
                      (e.g., law enforcement, National Guard, etc.).
                   Establishing communications between areas and to higher
                      headquarters, if possible.
                   Establishing the triage, decontamination, and holding areas.
                   Establishing a traffic pattern, which provides for the smooth flow
                      of bodies and vehicles in and out of the affected area.
                   Organizing medical personnel for staffing of the different areas.
                      Organizing nonmedical personnel for litter bearer duty
                      messengers restocking supplies, and other nonmedical functions.
                   Develop procedures that ensure timely, respectful, and culturally
                      sensitive evacuation and final care.
                   A temporary morgue site maybe established in proximity to the
                      incident site. If so, the location will need to be protected from
                      the elements and ensure appropriate security of the non-
                      survivors.
                   The non-survivors personal effects will need to be removed,
                      tracked, and secured.

WMD Training/Experience
 Gap in WMD Training
                    Some personnel within the ME‘s Office have completed WMD
                    training however, several key members need to complete WMD
                    training. At this time, the ME‘s office does not plan to send
                    additional staff for training.

Decontamination Policy/Procedures
                   No written policy or procedure regarding care, safe handling,
                      storage, decontamination, and final disposition (cremation,
                      burial, etc) has been developed.
                   The ME‘s Office is responsible for managing descendant‘s
                      personal effects. No policy has been written regarding safe
                      handling (i.e., double bagged, etc.), decontamination,
                      destruction, or final disposition of personnel effects.
                             Contacts for up to twelve refrigerated storage trucks have
                      been established and signed.



11/07/98                                                                               17
                                                                             City of Seattle
                                                            Seattle Fire Department (SFD)
                                                Metropolitan Medical Strike Team (MMST)
    Adequate PPE
                            While it is planned, the ME‘s Office has not procured a PPE
                             specific to safe handling of a contaminated WMD victim.
      Plan for Improving Non-Survivor
                 While the ME‘s office has discussed and begun planning for a WMD event.
                 Many of the policies and procedures regarding the care, safe handling,
                 evidence collection, decontamination, and final disposition of contaminated
                 bodies have not been formalized. Discussions have been held with members
                 of the ME‘s Office which suggest there is little interest in formalizing many
                 of these procedures. As an interim action, we will invite the ME‘s office to
                 participate in upcoming WMD/MCI exercises to better illustrate the benefits
                 of formalized procedures. In regards to training, we will continue to
                 encourage participation and suggest employees already trained provide in-
                 service to those employees who have not attended WMD classes.




    11/07/98                                                                                18
                                                                           City of Seattle
                                                          Seattle Fire Department (SFD)
                                              Metropolitan Medical Strike Team (MMST)

Critical Component # 6


    E. Seattle Emergency Operations Center (CS-EOC)                    MMST SYSTEM
       The primary responsibility for maintaining ―the peace
       and order‖ in the City of Seattle is vested in the Mayor by        Patient
                                                                        Movement     MMST
       the City Charter. All operational and service
       department heads are appointed by the Mayor, work
                                                                    Non-                      Hospital
       directly for the Mayor, and have been delegated the         Survivor       EOC         System
       day-to-day authority to administer their respective            s
       departments. Should a situation be serious enough to                                          E
                                                                            MHS
       warrant the use of any of the Mayor‘s ―emergency                                              M
                                                                                                     S
       powers‖, the Mayor will activate the City‘s Emergency
       Operations Center (EOC) and declare a ―Civil Emergency‖.                                      S
                                                                                                     y
                                                                                                     s
       In Seattle, day-to-day emergencies do not require activation of the EOC. All of               t
                                                                                                     e
       the City‘s operations departments operate using ―control centers‖. During routine             m
       operation these centers dispatch and support field personnel and their equipment.
       In a low- level emergency, an IC can request support directly from the individual
       department control center. If mass transportation is needed on scene, the IC
       request is routed directly to the responsible department‘s control center for action.
       It is the responsibly of the department control center to 1) notify key department
       official, 2) call off-duty personnel and arrange additional workforce requirements,
       3) monitor and keep records of departmental support and costs, and 4) call the
       EOC Staff Duty officer for assistance if resources become scarce. In additional,
       there IC can request the EOC Staff Duty Officer to activate the EOC when an
       emergency is of such magnitude it will require significant manpower or result is
       the request for multi-departmental resources.

       In a WMD event, the City of Seattle Emergency Operations Center (CS-EOC)
       will be the counterpoint of operations coordinating resources from multiple
       agencies and jurisdictions as well as technical expertise from a variety of
       disciplines. In contrast to the IC command post, which is concerned with
       activities at the scene, the EOC establishes priorities for the distribution of
       resources among the various sites, and handles off- incident concerns (e.g.,
       interactions with offsite facilities, such as shelters, ordering of resources, etc.)

       Under the Washington State Comprehensive Emergency Plan, whenever the CS-
       EOC is activated, it is required to inform and provide immediate situation reports
       and damage assessment to the Washington State EOC. Based on these reports,
       the State Emergency Management Division Duty Officer will make a finding for
       the Governor whether the emergency may require a Governor declaration.




11/07/98                                                                                        19
                                                                           City of Seattle
                                                          Seattle Fire Department (SFD)
                                              Metropolitan Medical Strike Team (MMST)
        Access to state resources, which include the National Guard, Emergency
        Management Assistance Compact (EMAC), and the Pacific Northwest
        Emergency Management Arrangement is through the CS-EOC.

        To ensure an effective WMD response, the EOC must successfully address
        the following key areas

             Information management
             Situation assessment
             Resource allocation
             Timely decisions

              3. Information Management/Situation Assessment
                  Much of information management, situation assessment, and resource
                  allocation for health and medical after a WMD event will be handled
                  through the EOC ESF-8 Coordinator. The Coordinator has decision-
                  making authority or direct access to Agency decision- makers. This
                  structure has been well planned and exercised in previous disasters.

                  The Seattle/King County Public Health Department is the primary
                  agency responsible for public health, medical, and mortuary respons e
                  (CS-ESF-8) during an emergency. It is supported by the Washington
                  State Hospital Association, Medical Exchange Northwest, and Amateur
                  Radio Emergency Service (ARES). CS-ESF-8 coordinates City
                  requirements for:

                     Emergency utilization of hospital, clinics, health care centers, and
                     critical care facilities; disease prevention and control; environmental
                     and health inspections; laboratory analysis of epidemiological
                     specimens and hazardous substance, and disposition of the dead.
                    Specialized support and services from local mental health
                     professionals, pharmaceutical suppliers, Puget Sound Blood Center,
                     and Poison Control Center.
                    Provides public health warnings and advisory through the
                     Department of Health
                   Activation of Hospital Control1 (Harborview Medical Ctr.). Hospital
                     Control serves as a physician-directed patient distribution center for
                     all transport patients. A back- up hospital has been pre-selected if
                     Harborview Medical Ctr. is lost in the event. Procedures have been
                     established and exercised for 1) hospital/bed reporting, 2) patient

1
    Under the City of Seattle Disaster Management Plan for Multiple Casualty Incidents (Section I
     501) the Hospital Control of the MCI will be the Deputy Medic al Director of Medic 1
     (Seattle/King County EMS) or his designate at Harborview Medical Center. He det ermines
     patient’s destination to area hospitals according to severity of injuries.


11/07/98                                                                                       20
                                                                          City of Seattle
                                                        Seattle Fire Department (SFD)
                                          Metropolitan Medical Strike Team (MMST)
                 tracking, 3) allocating and redirecting limited medical resources and,
                 4) directing requests for hospital resupply.

                Obtains supplemental health and medical assistance from the State
                 and Federal government by referring special health request through
                 the State EOC.

           3.7   Gaps in the EOC ESF-8 functions
                 The EOC is well designed and exercised. However, a number of
                 gaps remain, several have been addressed in the Health Care
                 Systems section under Public Health. The following are additional
                 issues that remain to be resolved in our planning:
                  Determination of pre-designated laboratory that would analysis
                      hazardous WMD substances in the Region.
                  Development of mass vaccination/drug distribution procedure
                  Development of formal procedure for quarantine
                  Develop prewritten public health warning and advisory
                  Develop procedure for the safe collection and disposal or animal
                      carcass contaminated with WMD agent




11/07/98                                                                              21
                                                                            City of Seattle
                                                           Seattle Fire Department (SFD)
                                               Metropolitan Medical Strike Team (MMST)

Critical Component # 7

    F.     Forward Movement of Victims                                        MMST
              SYSTEM
                                                                               Patient
         In coordination with the Hospital Control Physician, the City         Movemen MMST
         of Seattle‘s Emergency Operation Center (CS-EOC) ESF-8                    t

         Coordinator makes the determination when the community           Non-                   Hospital
                                                                         Survivor     EOC        System
         health care system has become overwhelmed and is no                s
         longer capable of providing appropriate definitive care for
                                                                                  MHS     EMS
         patients. Through the CS-EOC, the State EOC is notified of                      Syste
         the necessity to relocate patients out of the affected area.                      m

         Under the Washington State Comprehensive Emergency
         Management
         Plan, the State has several options to assist in forward movement.

               Emergency Management Assistance Compact (EMAC) is an interstate
                compact that provides for mutual assistance between states in managing
                gubernatorial-declared emergencies or disasters. The capacity for patient
                movement under EMAC is small (e.g., 2-10 patients) and it is unlikely this
                would be a viable alternative in a WMD event.

               Federal Response Plan. The Governor can request Federal assistance
                under the Robert T. Stafford Disaster Relief and Emergency Assistance
                Act. In general, the Governor requests a presidential declaration of a
                disaster or emergency through the FEMA Regional Director. Such a
                Presidential declaration triggers a series of Federal responses coordinated
                by FEMA. These may include activation of NDMS by the Assistant
                Secretary for Health, HHS when appropriate.

               Assistant Secretary of Health. A State Health Officer may request
                National Disaster Medical System (NDMS) activation by the Assistant
                Secretary for Health, HHS, in situation where there is no Presidential
                disaster declaration. Such activation would take place under the
                authorities provided by the Public Health Service Act.

               National Disaster Medical System (NDMS). Under NDMS, a
                Management Support Unit will be the primary Federal Response Plan
                (FRP), Health and Medical unit on scene to interface with the City of
                Seattle ESF-8, Hospital Control, and when appropriate, the Scene Incident
                Commander. The MSU will be the focal point for receiving, assigning,
                and directly or indirectly supporting the necessary Components (e.g.,
                Disaster Medical Assistance Teams, Clearing and Staging Units, Disaster
                Mortuary Units, etc.).




11/07/98                                                                                    22
                                                                     City of Seattle
                                                    Seattle Fire Department (SFD)
                                       Metropolitan Medical Strike Team (MMST)
    G. Preparation for Transportation of Victims out of Area

           When relocating patients out of the area, Casualty Collection Center(s) will be
           established at or near the point of departure (POD), where necessary. A
           Medical Services Officer (MSO) will be assigned to oversee the CCC by the
           IC. Staffing of the CCC will be by Seattle Fire/Paramedics or appropriately
           trained mutual aid EMT/Paramedics. The City of Seattle ESF-8 will
           coordinate staffing support with the Seattle/King County Department of
           Health and Hospital Control. Medical treatment will be continued until
           patient transfer to NDMS is complete. CCC guidelines used for transfer of
           patients out of the area are:

               Unstable patients will not be transported.
               Individuals who die while staged at the CCC will be relocated to the
                designated temporary morgue site, under the direction of the Seattle/king
                County ME.
               No victims will be evacuated prior to decontamination.
               For infectious cases, all members of the CCC will use proper respiratory
                PPE.
              Seattle MCI patient tracking procedures will be used until transfer to
                NDMS. The MCI tracking Manifest will be reconciled with the NDMS
                automated patient tracking system. Hospital Control will designate an
                information center to provide families information about where loved ones
                are being relocated.
               Pharmaceutical needs at the CCC will be supported through the CS-EOC
                ESF-8 Coordinator (Department of Health, MMST pharmaceutical cache,
                Area Hospitals, Military Support to Civilian Authorities).
              Law Enforcement will be responsible for security and traffic control into
                and out of the CCC.




11/07/98                                                                                23
                                                                                   City of Seattle
                                                                  Seattle Fire Department (SFD)
                                                      Metropolitan Medical Strike Team (MMST)

              METROPOLITAN MEDICAL STRIKE TEAM (MMST)

         TEAM OPERATIONS AND FIELD OPERATIONS GUIDE

                                 TABLE OF CONTENTS

                                                                                                     Page

I.           INTRODUCTION                                                                             3-1

             A.   Integration with State/Local Government                                             3-1
             B.   Integration with Federal Government                                                 3-7

II.          PROGRAM MANAGEMENT TEAM                                                                 3-10

             A.   Introduction                                                                       3-10
             B.   Coordination                                                                       3-10

III.         MMST MANAGEMENT AND COORDINATION                                                        3-11

             A.   Introduction                                                                       3-11
             B.   Arrival at the Assigned Locality                                                   3-11
             C.   Locating an Area for Setup of MMST Operations                                      3-12
             D.   Size Up/Operational Planning                                                       3-13
             E.   Interaction with the Local Command Structure                                       3-13
             F.   Work Scheduling/Rotations                                                          3-14
             G.   Arrival Procedures                                                                 3-14
             H.   Safety Considerations                                                              3-15
             I.   Demobilization Procedures                                                          3-15
             J.   Medical Surveillance                                                               3-16
             K.   Media Procedures                                                                   3-16

IV.          FIELD OPERATIONS GUIDE (FOG)                                                            3-17

             A.   INTRODUCTION                                                                       3-17

                  1.     Tactical Operations                                                         3-17

                         a.      Reconnaissance                                                      3-17
                         b.      Isolation                                                           3-18
                         c.      Work Period and Rehabilitation                                      3-18
                         d.      Protective Clothing                                                 3-19




11/ 05/ 10                                                                                            3-i
                                                                            City of Seattle
                                                           Seattle Fire Department (SFD)
                                               Metropolitan Medical Strike Team (MMST)

             2.   MMST Safety                                                                 3-20

                  a.     Introduction                                                         3-20
                  b.     Personnel Responsibilities                                           3-20
                  c.    Safety Risks and Hazards                                              3-20
                  d.    Medical Care for Injured MMST Members                                 3-21
                  e.    Passport Personnel Accountability System                              3-23
                  f.    Safety Concerns During MMST Operations                                3-23

             3.   Field Operations Overview                                                   3-28

                  a.     Introduction                                                         3-28
                  b.     Duties for the Field Operations Section Personnel                    3-28

             4.   Medical Considerations                                                      3-33

                  a.   Treatment Priorities                                                   3-33
                  b.   Triage                                                                 3-34
                  c.   Decontamination                                                        3-34
                  d.   Treatment                                                              3-35
                  e.   Casualty Collection Center (CCC)                                       3-35
                  f.   Emergency Transportation of Patients                                   3-36

             5.   Hospital Emergency Medical Services                                         3-39

                  a.   Integration into the Incident Command System                           3-39
                  b.   Pharmaceuticals                                                        3-39
                  c.   Pre-stocked NBC Pharmaceuticals                                        3-40
                  d.   Transportation Plan                                                    3-40
                  e.   Hospital Selections/Destinations                                       3-40
                  f.   WMD Medical Treatment Protocols                                        3-40
                  g.   Decontamination Capability                                             3-41

             6.   Forward Movement of Patients                                                3-42

                  a.    Extension of Existing NDMS Patient Transportation                     3-42
                  b.    Adaptation to a Mass Casualty Situation                               3-42
                  c.    Integration into the MMST System Response                             3-42

             7.   Mental Health Services                                                      3-43

                  a.    Mental Health Services in a Mass Casualty Situation                   3-43
                  b.    Mental Health Services for First Responders                           3-43
                  c.    Mental Health Services for Victims, Families and                      3-43
                        Local Community
                  d.    Integration into the MMST System Response                             3-44

11/ 05/ 10                                                                                     3-ii
                                                                                  City of Seattle
                                                                 Seattle Fire Department (SFD)
                                                     Metropolitan Medical Strike Team (MMST)



                  8.     Plans for Disposition of Non-Survivors                                      3-45

                         a.   Based on Existing Mortuary Services                                    3-45
                         b.   Adaptation to a Mass Casualty Situation                                3-45
                         c.   Crime Scene Considerations                                             3-45
                         d.   Integration into the MMST System Response                              3-45

                  9.     Planning Considerations                                                     3-46

                         a.   Introduction                                                           3-46
                         b.   Duties for the Plans Section Personnel                                 3-46

                  10.    Logistical Considerations                                                   3-47

                         a.   Introduction                                                           3-47
                         b.   Duties for Logistics Section Personnel                                 3-47
                         c.   Communications                                                         3-48

                  11.    Law Enforcement Considerations                                              3-50

                         a.   Introduction                                                           3-50
                         b.   Duties for the Law Enforcement Personnel                               3-50

             B.   POSITION DESCRIPTIONS AND OPERATIONAL CHECKLISTS                                   3-51

                         a.     Introduction                                                         3-51

                         Command Organization Chart                                                  3-53
                  I.     Command Group                                                               3-55

                         a.    Task Force Leader (TFL)                                               3-55
                         b.     Law Enforcement Liaison                                              3-61
                         c.     Safety Officer                                                       3-69
                         d.     Medical Director                                                     3-75
                         e.     Hospital Liaison                                                     3-79

                  Operations Section Organization Chart                                              3-85
                  II.    Field Operations Section                                                    3-87

                         a.     Operations Section Chief                                             3-87
                         b.     Field Medical Group Supervisor                                       3-91
                         c.     Field Medical Specialist                                             3-97
                         d.     Field Hazardous Materials Group Supervisor                          3-101
                         e.    Field Hazardous Materials Specialist                                 3-107


11/ 05/ 10                                                                                           3-iii
                                                                                   City of Seattle
                                                                  Seattle Fire Department (SFD)
                                                      Metropolitan Medical Strike Team (MMST)

                   Plans Section Organization Chart                                                  3-111
              III.    Plans Section                                                                  3-113

                     a.      Plans Section Chief                                                     3-113
                     b.      Plans Group Supervisor                                                  3-117
                     c.     Intelligence Information Specialist                                      3-121
                     d.     HazMat Information Specialist                                            3-125
                     e.     Medical Information Specialist                                           3-129

             Logistics Section Organization Chart                                                    3-133
             IV.     Logistics Section                                                               3-135

                     a.      Logistics Section Chief                                                 3-135
                     b.      Logistics Group Supervisor                                              3-141
                     c.     Logistics Specialist                                                     3-145
                     d.     Communications Group Supervisor                                          3-149
                     e.     Communications Specialist                                                3-155

             Team Medical Section Organization Chart                                                 3-161
              V.   Team Medical Section                                                              3-163

                     a.      Team Medical Section Chief                                              3-163
                     b.      Team Medical Specialist                                                 3-171




11/ 05/ 10                                                                                             3-iv
                                                                       City of Seattle
                                                      Seattle Fire Department (SFD)
                                          Metropolitan Medical Strike Team (MMST)



Appendix                                                                                 Page

A            METROPOLITAN MEDICAL STRIKE TEAM                                            3-A-1
             RECOMMENDED PHYSICAL EXAMINATION COMPONENTS

B            METROPOLITAN MEDICAL STRIKE TEAM
             INCIDENT EXPOSURE REPORT                                                    3-B-1

C            METROPOLITAN MEDICAL STRIKE TEAM
             PRE-/POST-ENTRY MONITORING FORM                                             3-C-1

D            METROPOLITAN MEDICAL STRIKE TEAM                                            3-D-1
             MEDIA PROCEDURES

E            METROPOLITAN MEDICAL STRIKE TEAM                                            3-E-1
             PATIENT DECONTAMINATION PROCEDURE

F            METROPOLITAN MEDICAL STRIKE TEAM                                            3-F-1
             TEAM MEMBER DECONTAMINATION PROCEDURE

G            METROPOLITAN MEDICAL STRIKE TEAM                                            3-G-1
             EMERGENCY DECONTAMINATION PROCEDURE

H            METROPOLITAN MEDICAL STRIKE TEAM                                            3-H-1
             HUMAN DECONTAMINATION SOLUTIONS

I            METROPOLITAN MEDICAL STRIKE TEAM                                            3-I-1
             MEDICAL TREATMENT PROTOCOLS

J            SIMPLE TRIAGE AND RAPID TREATMENT (START)                                   3-J-1
             SYSTEM

K            METROPOLITAN MEDICAL STRIKE TEAM                                            3-K-1
             EQUIPMENT STORAGE AND UTILIZATION




11/ 05/ 10                                                                                 3-v
                                                                                  City of Seattle
                                                                 Seattle Fire Department (SFD)
                                                    _Metropolitan Medical Strike Team (MMST )

              METROPOLITAN MEDICAL STRIKE TEAM (MMST)

             TEAM OPERATIONS AND FIELD OPERATIONS GUIDE


     The FOG is a compilation and summary of important strategic and tactical
     information. Position description summaries and complete operational checklists are
     outlined for each of the positions that make up the MMST.

     Use of, and adherence to, the FOG will ensure optimum personal and MMST
     performance.


I.      INTRODUCTION

        The United States Public Health Service, Office of Emergency Preparedness
        (USPHS/OEP) in partnership with the City of Seattle and the Seattle Fire
        Department (SFD) has supported the development of a Metropolitan Medical
        Strike Team (MMST) as a locally available, nuclear, biological, and chemical
        (NBC) trained incident response team.

        A. Integration with State/Local Gove rnment

            Because of Seattle‘s prominence as a major Pacific Rim crossroads and
            international center for trade and commerce, it serves as an attractive site for
            hosting major events. Oftentimes world leaders and other dignitaries attend
            these events, such as the Asian Pacific Economic Cooperation Conference,
            Goodwill Games and World‘s Fair. Conceivably, these people as well as
            celebrities and high profile organizations that are associated as sponsors
            and/or participants, could be viewed by domestic or foreign antagonists as
            hostile targets. Even the facilities used for the event, when transformed by the
            media into stages for a news spectacle, have the potential for becoming
            tempting targets for those bent on delivering a sinister political message
            and/or avenging a perceived injustice.

               (1) Deliberate Deployment

                   The Seattle Police Department (SPD) Criminal Intelligence Section is
                   assigned the responsibility for tracking ―pre-planned‖ events acting in
                   accordance with the mandates of the City of Seattle Ordinance
                   #108333, ―Collection of Information for Law Enforcement Purposes.‖
                   Through the Chief of Police or designate they keep the City‘s civil
                   leadership apprised of security threats that pose a serious danger to
                   people and/or property in Seattle.




11/05/10                                                                                     3-1
                                                                         City of Seattle
                                                        Seattle Fire Department (SFD)
                                           _Metropolitan Medical Strike Team (MMST )

           As proscribed in federal law they do this mainly by coordinating with
           the local FBI field office and with other regional and/or advance team
           representatives of federal investigative, diplomatic and intelligence
           agencies.

           Should a presumed terrorism threat (as defined in Title 18, USC,
           Section 2332a - Weapons of Mass Destruction) be the basis for
           recommending a heightening of normal security at a ―pre-planned‖
           event, the FBI is the lead federal agency for ―crisis management‖
           under Presidential Decision Directive (PDD) 39. Concurrently they
           would activate their Joint Operations Center (JOC) to establish a local
           venue for planning and organizing preventive and readiness measures
           considered appropriate.

           Such actions might include:

              Collaborating with the Strategic Information Operations Center
               (SIOC) at FBI Headquarters to arrange for pre-positioning of
               federal assets to forward staging locations
              Rehearsing joint ―crisis management‖ operations with the City
              Activating the Emergency Operations Center (EOC) for the event,
               etc.
              Working with the City‘s Disaster Management Committee (DMC)
               to ensure the City‘s unified command structure can effectively
               interface with and support federal operational and logistical
               involvement.

           Should the FBI receive intelligence and/or uncover evidence that
           would lead them to find that there is a ―credible threat‖ for an
           imminent weapons of mass destruction attack within the City, they
           would activate their JOC and immediately pass the threat information
           to the designated contact in the SPD Criminal Intelligence Section.
           This information would be provided to the Chair of the DMC, who
           would immediately direct the convening of a special meeting. The
           DMC would, with the help of the local FBI Special Agent In-Charge
           and the SPD Criminal Intelligence Section, review the information to
           determine the impact to the City and what proactive steps should be
           initiated to enable the City government to increase security and place
           appropriate response capabilities and assets in an increased state of
           readiness. Given the resulting ―size-up‖ that would be made at this
           meeting, an Action Plan would be developed to set EOC objectives
           and operational periods.

           The DMC Chair would brief the Mayor and obtain his approval of the
           action plan. As part of the action plan the Mayor would authorize the


11/05/10                                                                            3-2
                                                                           City of Seattle
                                                          Seattle Fire Department (SFD)
                                             _Metropolitan Medical Strike Team (MMST )

              briefing of other elected officials and state and county contacts. The
              Mayor would also (in consultation with the Director of
              Communications and others the Mayor may want to counsel with)
              decide how inquiries from the media and statements to the public
              would be handled.

              After briefing the Mayor, the DMC Chair would determine the timing
              for the next DMC meeting to reassess the current situation and to
              oversee implementation and necessary revision of the action plan. The
              above monitoring cycle will continue at scheduled intervals until the
              source of the threat is neutralized, the FBI no longer considers the
              threat credible, or an attack in Seattle is perpetrated.

           (2) Emergency Deployme nt

              Any time a major incident occurs in the City of Seattle, the City‘s
              emergency management system as described in the Seattle Disaster
              Readiness and Response Plan is implemented. This includes field
              response, augmentation of department dispatch/operating center
              staffing, department emergency notifications and Seattle Emergency
              Response Information System (SERIS) reporting, activation of the
              EOC (see EOC Organization Chart, page 3-5), and notification of state
              and county emergency management duty officers.

              If the cause of the incident stems from a previously identified
              ―credible threat‖, parts of the emergency management system will
              have already been engaged or standing by. The response will take
              advantage of local, state and federal resources that may have been
              pre-staged. It will also use lessons learned from rehearsals that may
              have been held to integrate multi-agency operability, and to use pre-
              designated incident command, communications and support facilities.

              If a no-notice incident occurs, the recognition of the use of a weapon
              of mass destruction or presence of an NBC agent, will have to be
              made by investigating first-response units. Under such a scenario and
              based on direction given by the Incident Commander, initial
              notifications will be made by the Fire Alarm Center (FAC) and SPD
              Communications primarily. It is the responsibility of both the FAC
              and SPD Communications in major incidents to notify the Emergency
              Management Staff Duty Officer (SDO) as soon as practical. SPD
              Communications will additionally alert Seattle Police Operations
              Center (SPOC) staff, the MMST Law Enforcement Liaison and SPD
              Duty Captain as needed. The MMST Law Enforcement Liaison or
              Duty Captain will ensure the FBI has been notified.




11/05/10                                                                              3-3
                                                                             City of Seattle
                                                            Seattle Fire Department (SFD)
                                               _Metropolitan Medical Strike Team (MMST )

           As outlined in the Seattle Disaster Readiness and Response Plan, the
           SDO would take steps to initiate the activation of the EOC. Once
           EOC staffing reaches a level to sustain operations, it will assume its
           executive leadership mission to anticipate and support field
           requirements that tax department resources (see EOC organizational
           chart).

           At the outset the Mayor has the authority to proclaim a ―Civil
           Emergency‖ and exercise appropriate ―emergency powers‖.
           Emergency Management staff would notify the state Emergency
           Management Duty Officer and ask for a state mission number to
           indemnify ―emergency workers‖. The King County Emergency
           Management Duty Officer would also be notified. Department
           reporting to the EOC would follow guidelines given in Annex F to the
           City‘s Disaster Readiness and Response Plan.

           The Mayor will make the decision on how public information is
           administered. In a weapons of mass destruction incident it can be
           assumed that the Director of Communications will activate the PIO
           Team and manage public information from the EOC.

           Requests for outside assistance (if not otherwise covered by an
           existing mutual aid agreement) is required to be authorized by the
           Mayor. This includes asking the state and federal governments for
           assistance, (see WMD Crisis/Consequence Management Organization
           Chart on page 3-6). It is critical that any request from the Incident
           Commander or department operating center be referred to the EOC
           without delay. In relating these requests it is very important to
           specify:

              The exact type of resource needed,
              Special specifications required to use the resource,
              When it is needed,
              The location it is needed at,
              What it is going to be used for,
              How long it will be needed.




11/05/10                                                                                3-4
                                                             City of Seattle
                                            Seattle Fire Department (SFD)
                               _Metropolitan Medical Strike Team (MMST )




           Place EOC Org. Chart Here




11/05/10                                                                3-5
                                                                   City of Seattle
                                                  Seattle Fire Department (SFD)
                                     _Metropolitan Medical Strike Team (MMST )




           PLACE WMD/CRISIS CONSEQUENCE PRG. CHART HERE




11/05/10                                                                      3-6
                                                                                 City of Seattle
                                                                Seattle Fire Department (SFD)
                                                   _Metropolitan Medical Strike Team (MMST )

B. Integration with Federal Governme nt

      The laws of the United States assign primary authority to the Federal Government
      to prevent and respond to acts of terrorism, State and local governments provide
      assistance as required. Measures needed to anticipate, prevent, and/or resolve a
      threat or act of terrorism (Crisis Management) are predominantly law enforcement
      activities and are the responsibility of the Federal Bureau of Investigation (FBI).

      In a terrorist event, the FBI will operate in a unified command structure with the
      Seattle Incident Commander during the response and resc ue phases. At some
      point after viable victims have been removed and the priority shifts to crime scene
      management, primary control will shift to the FBI Special Agent in Charge
      (SAIC), and local responders will operate in support of the FBI.

           The laws of the United States assign primary authority to the States to respond
           to the consequences of terrorism, the Federal government provides assistance
           as required. Protecting public health and safety, restoring essential
           government services, and providing emergency relief to government,
           business, and individuals affected by an act of terrorism (Consequence
           Management) are State responsibilities. Under the Federal Response Plan
           (FRP), the Federal Emergency Management Agency (FEMA) has the lead in
           assisting States affected by the consequences of terrorism.

      In any scenario, it must be recognized that Federal Agencies and, therefore,
      resources will not likely be activated and mobilized prior to the critical elements
      of an NBC event being addressed by local responders. Only if the event length
      exceeds the 24-36 hour time frame will most Federal Agencies arrive at the
      Incident Command Post (ICP) to provide support. Most Federal assets can be
      accessed through the SAIC on-site representative. Some additional avenues for
      accessing Federal assets are listed below.

           1. Accessing Fede ral Resources Before a Presidentially Declared
           Emergency

                  In a Presidentially declared emergency, most Federal Agencies
                  provide assistance to the State through the direction of FEMA, under
                  the authority of the FRP. Federal resources are not widely available
                  without a presidentially declared emergency. However, in radiological
                  emergencies, actual or potential release of hazardous materials, or
                  threats to public health some Federal Agencies have an independent
                  authority that allows response outside the FRP. These agencies can
                  offer local authorities critical guidance, advice, and technical support
                  in the early phases of a terrorist event.




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                                                                         City of Seattle
                                                        Seattle Fire Department (SFD)
                                           _Metropolitan Medical Strike Team (MMST )

           The Incident Commander should note that much of these resources
           overlap and can be triggered through multiple avenues. Prior to the
           FRP being activated, local authorities can secure technical assistance
           in the following manner:

           (a) Nuclear Incident

              The Department of Energy (DOE) has independent authority to
              provide technical assistance and respond to a nuclear incident. As
              part of DOE, the Radiological Assistance Program (RAP),
              provides the initial on or near scene assessment and can assist the
              Incident Commander with identifying other appropriate DOE
              resources.

              The nearest RAP is located in Richland, WA and can deploy a
              Radiological Assistance Team (RAT) within two hours. In a
              suspected or actual nuclear incident, local authorities can request
              "Radiologic Assistance" from the RAP 24 hours a day, 7 days a
              week, by calling the Richland Operations Office at (509) 373-
              3800.

           (b) Hazardous Materials Incident

              Within the Federal government, the Environmental Protection
              Agency (EPA) has the independent authority to respond to a
              HAZMAT incident.
              The EPA‘s ―Emergency Response Unit‖ (ERU) provides the initial
              assessment and has the capabilities to provide rapid on-site support
              for 1) air monitoring, 2) air flow modeling, 3) initial site
              evaluation, 4) sampling and, 5) limited radiation monitoring. In
              addition, the ERU can assist the Incident Commander with
              identifying other appropriate EPA resources.

              Local technical assistance can be requested 24-hours a day, 7-days
              a week by calling the ―Duty Officer‖ for the Region X Emergency
              Response Unit at (206) 553-1263.

           (c) Health and Medical Issues

              Office of Emergency Preparedness, U.S. Public Health Service
              Region X, can assist local/State health officials in establishing
              immediate communication linkages with the Federal health
              experts. This linkage allows for rapid consultation and exchange
              of medical information with local medical experts regarding




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                                                                                City of Seattle
                                                               Seattle Fire Department (SFD)
                                                  _Metropolitan Medical Strike Team (MMST )

                     treatment protocols, decontamination practices, or patient
                     management issues.

                     In Seattle, State or local health officials can contact OEP by calling
                     or paging the ―Emergency Coordinator‖ at (206) 615-2469 or
                     Pager 800-759-8888 PIN #2040965.

                 (d) Other Technical Assistance

                     Under PDD-39, authority for crisis management of a terrorist
                     threat/event is delegated to the FBI. Because of this design, the
                     earliest Federal presence at an incident is expected to be the FBI‘s
                     Special Agent in Charge. The Incident Commander should
                     understand that advice or expert guidance could always be
                     requested through the FBI to a specific Federal Agency (e.g., CDC,
                     EPA, DoD, DOE, etc.)

                 (e) Hotline Lines

                     The Department of Defense and the Nation Response Center can
                     provide chemical and biological technical assistance through the
                     following hotlines:

                        Domestic Preparedness Hot Line – (800) 368-6498
                         NonEmergency chemical/biological information. 9 AM – 6
                         PM (EST)

                        National Response Center Hot Line – (800) 424-8802
                         Emergency chemical/biological information 24 hrs/day, 7 days
                         a week.

           2. After a Presidentially Declared Emergency

      In a Presidentially declared disaster, Federal Agencies provide assistance to a
      State through the direction of FEMA, under the authority of the FRP. FEMA is
      the lead Federal Agency in consequence management and is responsible for
      coordinating the Federal response to the consequence of a terrorist event. Local
      requests for assistance should be directed to the State Coordinating Officer who
      will forward the request to FEMA‘s Federal Coordinating Officer.




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                                                                                  City of Seattle
                                                                 Seattle Fire Department (SFD)
                                                    _Metropolitan Medical Strike Team (MMST )

II.   PROGRAM MANAGEMENT TEAM

      A.       Introduction

      The Program Management Team (a subcommittee of the Seattle Disaster
      Committee) consists of a committee composed of a Chair, (Seattle Fire
      Department Assistant Fire Chief) and a representative from the Seattle Police
      Department, the City of Seattle Emergency Operations Center and the
      Seattle/King County Department of Public Health. This gro up will utilize a
      subgroup composed of subject experts from the field to accomplish the
      functions/tasks below:

          Response Team
          Ambulance Transport
          Hospital Treatment
          Mental Health
          Non-Survivors
          Forward Movement of Patients
          Crime Scene
          Inter-agency Coordination

B. Coordination

      Listed below are the duties of the Program Management Team:

              Shall represent Seattle at national meetings.

              Coordinate team activities on a Local, State and Federal level.

              Coordinate to ensure that the MMST response plan is kept current, that all
               medical and training requirements are met, and that all required forms are
               current.

              Coordinate the development and scheduling of exercises and teamwide
               training sessions.

              Assure training programs are devised and presented for area first
               responders (police, fire and EMS) as well as the local medical community.

              Coordinate the development and distribution of educational materials
               concerning the MMST.




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                                                                                 City of Seattle
                                                                Seattle Fire Department (SFD)
                                                   _Metropolitan Medical Strike Team (MMST )

              Coordinate with Federal agencies and DoD units for sharing information,
               for establishing joint exercises, and for other purposes found in the MMST
               mission statement in Section I.

              Keep the Mayor, City Council, Fire Chief and Police Chief apprised of
               team status and pertinent operational and training issues through the
               Disaster Management Committee.


III.       MMST MANAGEMENT AND COORDINATION

       A. Introduction

          A 62-person Seattle MMST Task Force comprises five major functional
           elements (Command, Operations, Plans, Logistics, and Medical) and
           associated supervisory positions.

          The TFL receives direction and coordinates with the local IC, implements
           strategic and tactical assignments, and provides the necessary information
           flow for proper incident management.

              Due to the mission requirements of the MMST, qualified fire service
               personnel will fill team positions, unless otherwise stipulated.

       B. Arrival at the Assigned Locality

              Upon arrival, the TFL should obtain a briefing from the IC to establish the
               current situation and determine how the MMST can assist in the incident.

              The existing chain of command and, specifically, to whom the TFL
               reports must be quickly established to ensure continuity throughout the
               operation.

               The TFL should address the following points:

               -   Physical location of the ICP is appropriate for the problem
               -   Location of the Task Force Base of Operations (BOO)
               -   Who, by position, is the TFL point of contact (POC)
               -   Current situation
               -   Agent identification issues
               -   Victim decontamination issues
               -   Victim transportation issues
               -   Fatality processing issues


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                                                                                 City of Seattle
                                                                Seattle Fire Department (SFD)
                                                   _Metropolitan Medical Strike Team (MMST )

               -   Hospital management issues
               -   Facility decontamination issues
               -   Local medical system issues
               -   Support for the MMST
               -   Current meteorological conditions
               -   Team composition
               -   Capabilities
               -   Limitations
               -   Specific support requirements
               -   Integration into the jurisdiction‘s Incident Command System/Incident
                   Management System (ICS/IMS)
               -   Security measures to be followed

               In addition, the locality should identify any political or sensitive
               considerations specific to the current situation, in accordance with the City
               of Seattle Ordinance #108333, ―Collection of Information for Law
               Enforcement Purposes.‖

      C. Locating an Area for Setup of MMST Operations

              While en route to the incident site, the TFL should coordinate with the IC
               to determine an area for the MMST to set up operations (Task Force
               BOO).

              Key factors in determining this BOO site include:

               -   Travel distance and designated safe access routes to the scene
               -   Proximity to the ICP
               -   Proximity to the hot, warm, and cold zones
               -   Personnel shelter
               -   Communications
               -   Site safety/security
               -   Wind direction

              Once on-scene, MMST personnel must ensure adequate space is available
               for:

               -   Equipment cache setup and maintenance
               -   Operations shelter for MMST personnel
               -   Medical treatment area
               -   Decontamination (victim and team members)
               -   Toilet and sanitation area (in long-term operations)
               -   Rehabilitation area




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                                                                                        City of Seattle
                                                                       Seattle Fire Department (SFD)
                                                          _Metropolitan Medical Strike Team (MMST )

      D. Size Up/Operational Planning

              After being briefed on what actions have taken place, the TFL should
               continue operational planning:

               -   Has Incident Command been established?
               -   Determine the physical magnitude of incident: How much square area
                   is affected?
               -   Have identification and extent of agent proliferation been established?
               -   Has site control been initiated and have physical zone perimeters been
                   established?
               -   Have local medical facilities been notified of the event?
               -   Has the Hospital Control System been implemented?
               -   Are local Hazardous Materials (HAZMAT) teams preparing for
                   entry to determine the type of agent?
               -   What level of Personal Protective Equipment/Chemical Protective
                   Clothing (PPE/CPC) is needed?
               -   Has a preliminary victim count been taken?
               -   Will MMST entry teams be needed?
               -   Have hospitals that will receive casualties been determined and
                   notified?
               -   Have triage areas been established?
               -   Has transportation area been established?
               -   Have emergency decontamination capabilities been established?
               -   Is law enforcement support in place?

      E. Interaction with the Local Command Structure

              Upon arrival at the incident scene, the MMST TFL must become an
               integral part of the existing command structure:

               -   The TFL should be prepared to adapt to different variations of ICS that
                   may be implemented by the authority having jurisdiction.
               -   It should be understood by the incident jurisdiction that the MMST is a
                   resource that is available for their use and under their operational
                   direction.
               -   This interaction must be conducted in a cooperative manner.

              The TFL must identify to the IC any support needs of the MMST, such as:

               -   On-site replen ishment of equip ment and supplies (decon treatment, etc.).

               -   Increased on-site medical expertise.
               -   Provisions for long-term operations (food, water, sanitary facilities,
                   rest areas, pharmaceuticals, etc.).


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                                                                                 City of Seattle
                                                                Seattle Fire Department (SFD)
                                                   _Metropolitan Medical Strike Team (MMST )

      F. Work Scheduling/Rotations

              When the MMST arrives at the assigned location, it may be necessary to
               commit all personnel to the initial requirements that must be addressed
               including:

               -   BOO setup
               -   Communications equipment setup
               -   Equipment/cache setup and breakout
               -   Decon setup

              The TFL must consider the magnitude of the event, whether it is a single
               or multiple site incidents, and will determine the resources needed.

              Activation of all team members can be accomplished by using our
               established notification system.

              Most NBC events will have a relatively short duration for the successful
               rescue of viable victims (i.e., usually no more than 3 hours). However, the
               more expeditious and aggressive the actions taken in the initial stages of
               the event, the more victims will be recovered and can be decontaminated,
               initially treated and transported to medical facilities.

              If it appears that the MMST will be operating on site for more than 4
               hours, provisions should be made for rotating personnel through entry,
               decontamination, and rehab support.

      G. Arrival Procedures

              Identify the Incident Commander and relay the following:

               -   Provide a brief overview of the team‘s capabilities and identify ke y
                   personnel
               -   State the limitations of the team and expected duration of the mission
               -   Identify areas where the team can provide assistance
               -   Determine the on-site command system

              Obtain information on what activities have taken place since the beginning
               of the event.

               -   Current situation and continuing threat level (suspecting scene,
                   secondary devices, etc.)
               -   Agent identification



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                                                                                  City of Seattle
                                                                 Seattle Fire Department (SFD)
                                                    _Metropolitan Medical Strike Team (MMST )

               -   Estimated size of the agent envelope
               -   Potential number of victims

              Plan how the MMST will be deployed.

               -   Will entries be necessary?
               -   For victim triage, decontamination, and transport
               -   For deployment to local medical facilities to support their efforts

              Initiate the Personnel Accountability System.

      H. Safety Considerations

              MMST operations constitute one of the most complex and dangerous
               activities emergency responders may encounter.

              Fundamentally, MMST operations are dependent upon various disciplines
               working in close concert with each other.

              If any team element fail to carry out their respective assignment in a safe
               and professional manner, the risk of injury to, or death of, a team member
               is greatly increased.

              The TFL should ensure that the team BOO is located an adequate distance
               upwind and in a position that if evacuation of that site is necessary, it can
               be done in a timely fashion.

              All team members must adhere to the directives issued by the MMST
               Safety Officer.

      I. Demobilization Procedures

      Because the incident may be a crime scene, the MMST TFL must coordinate with
      the primary law enforcement agency, or the FBI, before initiating de mobilization
      procedures

              Account for all MMST personnel

              Ensure all assigned activities are completed

              Ascertain from IC if other assistance is required of MMST




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                                                                                  City of Seattle
                                                                 Seattle Fire Department (SFD)
                                                    _Metropolitan Medical Strike Team (MMST )

              Assist and coordinate with primary law enforcement to ensure all injured
               personnel and fatalities are properly processed and transported to
               appropriate facilities

              Ensure accountability of MMST tools and equipment

              Clean up debris/trash associated with MMST operations

              Ensure any biohazards and other contaminated equipment/ supplies are
               properly packaged and disposed of

              Coordinate transportation home

              Notify the local IC when the team leaves the site

      J. Medical Surveillance

              Team members must have an annual HAZMAT physical with baseline
               heart, lung, blood, neurologic, and kidney functions documented and in
               accordance with established standards.

              Team members wearing PPE will have pre- and post-entry monitoring
               done as outlined in Section 11, Medical Surveillance Guidelines.

              The TFL will ensure that there is a post-incident debriefing at the
               completion of each mission.

              The TFL will ensure that post- incident medical evaluations are done as
               outlined in Section 11, Medical Surveillance Guidelines.

      K. MMST Media Procedures

              Team members are not permitted to release incident information unless
               coordinated with the MMST PIO.

              Media management procedures must be identified early in the incident.

               -   This responsibility rests with the IC.

               -   All MMST members must clearly understand the procedures
                   established by the local jurisdiction and the TFL for interacting with
                   the different types of media.

               -   The MMST Plans Section Chief will act as the MMST PIO.


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                                                                               City of Seattle
                                                              Seattle Fire Department (SFD)
                                                 _Metropolitan Medical Strike Team (MMST )



              Refer to the Operational System Description, Section 7, PIO-Media
               Relations, for further specifics.




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                                                                                   City of Seattle
                                                                  Seattle Fire Department (SFD)
                                                     _Metropolitan Medical Strike Team (MMST )

IV.            FIELD OPERATIONS GUIDE

        The City of Seattle, Seattle Fire Department‘s, Metropolitan Medical Strike Team
        Field Operations Guide (FOG) has been developed to assist MMST members
        during training and on mission assignments. The FOG is a compilation and
        summary of important strategic and tactical information. Position description
        summaries and complete operational checklists are outlined for each of the
        positions that make up the MMST. Use of, and adherence to, the FOG will ensure
        optimum personal and MMST performance.


      INTRODUCTION

              This document outlines the current tactical capabilities and general
               strategies that constitute a foundation for productive nuclear, biological, or
               chemical (NBC) incident mitigation. All MMST personnel must have a
               solid understanding of these guidelines.

              MMST personnel must tailor the general strategy and tactics to fit the
               specific situation encountered.

              It is incumbent on the Task Force Leader (TFL) and section officers to
               implement coordinated tactics and strategy, collect and collate related
               information, and develop an effective overall MMST action plan.

              The most effective strategies will blend all viable tactical capabilities into
               a logical plan of operation. Law Enforcement considerations may take
               precedence depending on the situation at the scene.




1.             Tactical Ope rations

The following general tactical operations are defined:

        (a) Reconnaissance

              It is critical in NBC incidents that the agent or material be identified as
               soon as possible to begin early, comprehensive medical intervention.

              Victims‘ signs and symptomology can serve as early indicators of the type
               of agent involved. As an example, a nerve agent produces convulsions,
               miosis, and uncontrollable defecation and urination, whereas phosgene


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                                                                                 City of Seattle
                                                                Seattle Fire Department (SFD)
                                                   _Metropolitan Medical Strike Team (MMST )

               may produce irritation and redness of the skin, increased presence of blood
               in the eyes, and possible ultimate cardiac collapse.

              Presence of a haze, mist in the air, or unusual odors suggests the presence
               of a chemical agent.

              Using the appropriate detection and monitoring equipment, team
               personnel must determine the extent of the agent or material envelope in
               order to establish hot, warm, and cold zones.


      (b) Isolation

              Once an area has been identified as affected, that area(s) needs to be
               isolated into the three primary zones: hot, warm, and cold.

              Unaffected persons outside the affected area must be prevented from
               entering the warm or hot zones.

              Consideration must be given to wind direction and speed when
               establishing critical zones and determining the agent envelope.

              Affected persons inside the hot and warm zones (victims) must be triaged
               according to the severity of their exposure to the agent or material.

              Obtaining agent or material samples will expedite identification.
               However, caution should be used if the dissemination device is discovered
               because it may contain a secondary explosive device.


      (c) Work Period and Rehabilitation

              It is extremely important that all team members be cognizant of the
               weather conditions when operating at NBC incident sites. The protection
               needed to maintain a safe personal environment can also work against the
               member by elevating the ambient temperatures to dangerous levels,
               particularly if the member must remain in an encapsulated garment for
               long periods of time.

              Entry and decon teams must have vital signs recorded prior to entry and
               upon exit from the decon area.
              Team members working in any form of personal protective equipment
               (PPE) will work strictly within the timeframe assigned by the MMST
               Safety Officer for the incident. Their decision, however, must be based on
               input from the Operations Section Chief, the Field HazMat Group


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                                                                                  City of Seattle
                                                                 Seattle Fire Department (SFD)
                                                    _Metropolitan Medical Strike Team (MMST )

               Supervisor and the Field Medical Group Supervisor. Further
               considerations affecting this timeframe are environmental conditions
               (temperature, humidity, barometric pressure, etc.), dangers involved, and
               personnel resources available.

              Members who have completed their assignment and are exiting the decon
               area (entry team or decon team) will immediately report to the rehab area
               for rest, observation, and post assignment examination.

              The rehab area will have the refreshments appropriate to maintain team
               members' health.

              Resources permitting, members will not be reassigned to an entry team or
               decon team until an adequate rest period has elapsed.


      (d) Protective Clothing

              Having the appropriate protective clothing is essential for the safety of
               team members operating at an NBC incident site.


              Unless otherwise warranted, entry team members will wear only level
               ‗‘A‘‘ encapsulated suit ensembles with self-contained breathing apparatus
               (SCBA) and appropriate boots, gloves, helmets, and functional identifiers.


              Team members operating in the decon area will have the appropriate level
               of protection as determined by the MMST Safety Officer (usually one
               level below that used by the entry team).


              Members operating in the Command Post area will wear helmets and
               functional identifier that denote their team position and have immediately
               available their ‗‘GO‘‘ kits, which contain masks, suits, gloves, and nerve
               agent antidote.

2.    MMST SAFETY

      (a) Introduction

              MMST operations constitute one of the most complex and difficult
               activities emergency responders may encounter.




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                                                                                  City of Seattle
                                                                 Seattle Fire Department (SFD)
                                                    _Metropolitan Medical Strike Team (MMST )

              Fundamentally, MMST operations are dependent on various disciplines
               working in close concert with each other.

              If any MMST element fails to carry out its respective assignment in a safe
               and professional manner, the risk of injury to, or death of, a MMST
               member is greatly increased.


      (b) Pe rsonnel Responsibilities

              MMST management personnel have the primary responsibility to ensure
               that good safety practices are identified in their operational action plans,
               during MMST briefings and critiques, and ensure that all operations are
               monitored for compliance.

              Even though there is a MMST Safety Officer, it is important to emphasize
               that safety is not some other person‘s exclusive responsibility. Everyone
               involved in the MMST mission must equally share it.

              All members of the MMST assume a personal responsibility to conduct
               their assignments in a professional and safe manner.

              All MMST personnel have the responsibility to identify unsafe acts and
               hazardous conditions, report them to their supervisors, and, if possible,
               mitigate such situations.


      (c) Safety Risks and Hazards

              Personnel conducting MMST response activities are exposed to many
               risks/hazards when carrying out assignments, including:

              Chemical, biological, or radiological agents
              Unstable structures and uneven footing
              Falling material or flying objects
              Exposure to hazardous materials
              Excessive noise, dust, smoke, and fire
              Confined space operations
              Contaminated air and water
              Dangerous equipment
              Armed thieves and looters
              Heavy lifting, excessive fatigue, and stress
              Adverse weather
              Unfamiliar work surroundings


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                                                                                 City of Seattle
                                                                Seattle Fire Department (SFD)
                                                   _Metropolitan Medical Strike Team (MMST )



                If safety is compromised by anyone at any time, the consequences could
                be serious.


      (d)       Medical Care for Injure d MMST Members

            (i) General Guidelines

           Any MMST member requiring medical attention shall have documentation
            completed, including:

            -   The MMST Patient Care Form
            -   The sponsoring agency's internal reports and forms
            -   Appropriate Federal and local forms

           The Project Management Team will assist with all of the documentation to
            support follow-up investigation (Workmen's Compensation, etc.).

           Final decisions concerning medical care will rest with the Medical Director
            and Team Medical Section Chief.

           The Team Medical Section Chief will indicate to the Task Force Leader the
            duty status of any ill or injured MMST member, (including remaining on
            incident, assigned light-duty status, relieved of duty, and returned home).

           The MMST Team will medically stabilize any injured MMST member
            requiring evacuation from the incident site prior to transport.

           The Hospital Liaison will determine the optimal medical destination and
            method of transport.

           An MMST member may be assigned to escort the injured member to assure
            optimal care for the injured member.

           The TFL will ensure the communication of pertinent details through the local
            Incident Command Post (ICP) and appropriate government channels back to
            the injured member's sponsoring organization and the Program Director
            (Seattle Fire Department‘s Assistant Fire Chief).

           The TFL or designee will brief all personnel on the accident, the member's
            condition, destination, and care provided. As appropriate, periodic updates of
            a MMST member's injuries and condition will be conducted as warranted.




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                                                                                    City of Seattle
                                                                   Seattle Fire Department (SFD)
                                                      _Metropolitan Medical Strike Team (MMST )

      (ii) Follow-up for Injured Team Membe rs

                 The Team Medical Section Chief will assure that MMST members cared
                  for by the MMST Medical Team receives referrals and follow-up of their
                  medical problems as indicated.

                 The Safety Officer will work with the Program Management Team (PMT)
                  to assure all necessary paperwork is submitted in a timely fashion.


      (iii)       Death of a MMST Membe r

                 Until determined otherwise, the death of an MMST member is part of a
                  crime scene. The responsibility for the crime scene remains with the
                  primary law enforcement agency.

                 In the event of the death of a MMST member, the Safety Officer and the
                  Team Medical Section Chief will verify the identity and confirm the death
                  of the individual. The probable cause of death should be specified, if
                  possible. The information must be provided to the TFL as soon as
                  possible.

                 Security should be ensured for the deceased member's personal items,
                  such as wedding rings, jewelry, etc.

                 The TFL may assign a MMST member to accompany the team member's
                  remains to the medical examiners office. Transfer of the remains will be
                  coordinated with the local incident command staff, the primary law
                  enforcement agency and the medical examiner.

                 The Safety Officer will initiate all appropriate documentation to record the
                  details regarding the cause of death and support the follow-up
                  investigation.

                 The TFL will assess the stress impact of the accident/incident on MMST
                  personnel and determine its further operational capability.

                 Family notification will be done in accordance with the team member
                  agency‘s policy. NO information is to be released to the media until
                  assurances have been made that proper family notification has been
                  completed. It will be the responsibility of the individual's agency to
                  initially notify the family. However, upon completion of the mission, the
                  TFL and/or their designee will express the support of the MMST to the
                  deceased member's family as soon as possible.



11/05/10                                                                                     3-23
                                                                                   City of Seattle
                                                                  Seattle Fire Department (SFD)
                                                     _Metropolitan Medical Strike Team (MMST )

               Primary responsibility for funeral arrangements and family support will
                rest with the MMST member's employment agency, with additional
                support provided by the Task Force Leader.

               The Safety Officer will work with the MMST employer and family to
                assure the necessary death benefit paperwork is promptly handled.


      (e)       Passport Pe rsonnel Accountability System

               All personnel are expected to maintain their personal passport.

               All personnel are to submit their respective passport to their immediate
                supervisor.

               During personnel accountability checks, the TFL will indicate to the IC
                the status of MMST personnel.

               The Law Enforcement Liaison will coordinate issuance of passports to law
                enforcement resources.


      (f)       Safety Concerns During MMST Operations

            (i) Prior to activation:

           It is necessary to evaluate safety concerns not only prior to an activation but
            also during every phase of MMST operations, from the time of activation
            through deactivation/demobilization.

           Although the risk of injury to MMST personnel is greatest during incident
            operations, injuries can also occur at other times. A number of safety
            considerations associated with each phase of MMST missions are listed
            below.
           Safety considerations to be covered for the following general categories of a
            mission response are:

               Preparedness
               Mobilization
               Incident operations
               Post-incident activities

           The best way to ensure the proper emphasis on safety is to develop a strong,
            positive attitude towards such during MMST development, training sessions,
            and field exercises.


11/05/10                                                                                    3-24
                                                                                City of Seattle
                                                               Seattle Fire Department (SFD)
                                                  _Metropolitan Medical Strike Team (MMST )



          It is important that all procedures and processes receive a thorough review by
           MMST officers to ensure that safety practices are appropriately addressed.

          The equipment cache inventory should be checked to ensure that personal
           safety equipment is adequate and available to meet the requirements for
           mission response.

          Issues related to safe and effective use of cache equipment should be assessed
           such as:

                Tool use and maintenance manuals on file and available in each
                 transport container
                Adequate stock of personal safety equipment
                Cache tools, supplies, and equipment mission ready, properly
                 inventoried, and stock rotated and/or replaced, as required

          Safety concerns for MMST personnel are:

              Assessment of their physical fitness and mental well being
              Successful completion of a physical exam
              Proper inoculations
              Personal gear/day pack organized, available
              Appropriate personal safety equipment on hand

          Training/demonstration of safe operating practices and procedures should be
           conducted for all MMST personnel for:

                  Wearing/operating in personal protective clothing
                  Power tools and specialized equipment
                  Hazard identification/mitigation
                  Decontamination
                  Lifting/carrying heavy objects
                  Emergency signaling
                  Confined space operations
                  Radio use
                  Personal survival and hygiene
                  Emergency care




11/05/10                                                                                 3-25
                                                                                  City of Seattle
                                                                 Seattle Fire Department (SFD)
                                                    _Metropolitan Medical Strike Team (MMST )

      (ii)       At mobilization site:

            The conduct of safe practices and procedures must be firmly established at the
             inception of a mission. This sets the tone and impacts all operations
             throughout a mission.

            If safety is made the prime consideration by the MMST management
             personnel, and emphasized during MMST briefings, personnel should react
             and demonstrate positive attitude toward safety practices and procedures.

            As personnel are processed in for a mobilization, the following issues should
             be addressed:

                -   Personnel arrive prepared and with proper gear
                -   A review of their mental/physical condition
                -   The removal of jewelry, rings, watches, etc.

            Safety concerns when MMST personnel are operating around/near fixed-wing
             aircraft and/or helicopters are:

                -   Eye/ear protection in place in ramp area
                -   Restricted use of portable radios
                -   Proper attire for cold experienced during flight
                -   Harness/tiedown for canine during takeoff/landing
                -   Access/control of MMST personnel in pallet buildup/ flight line area
                -   Safety briefing/use of aircraft hand signals emphasized


      (iii) On-site operations:

            MMST personnel will be most exposed to dangerous risks and hazards during
             the search-and-rescue and decontamination phases of operation.

            MMST personnel must occasionally review all logistics and operational
             activities to ensure that associated risks are identified and addressed
             expeditiously.

            Potentially dangerous conditions could occur separately or simultaneously.
             This may create an undesirable environment that could result in serious injury
             or death to MMST personnel.

            Safety assessments should be identified and factored into:

                -   Base of Operations site selection



11/05/10                                                                                   3-26
                                                                                 City of Seattle
                                                                Seattle Fire Department (SFD)
                                                   _Metropolitan Medical Strike Team (MMST )

              -   Operation work area zones and cordons
              -   MMST support facilities locations (rehab, treatment section, etc.)

          Safety issues should be highlighted during operational briefings to include:

              -   Rescue site signaling and escape routes
              -   Emergency decon procedures
              -   Use of command position vests
              -   Medivac procedures identified/in place

             Safety issues to consider related to scene security are:

              -   Sniper
              -   Barricaded suspects
              -   Suspect on-scene, armed
              -   Hostages
              -   Secondary devices
              -   Crowd control
              -   Theft

          Safety concerns related to search/rescue and decontamination work sites are to
           include:

              -   Ensure that safety considerations are incorporated in the development
                  of work plans
              -   Operations, including logistical activities, must be monitored for safe
                  practices and procedures
              -   Ensure that significant/unique hazards are identified
              -   Radio communications must be continually monitored
              -   Enforcement of personnel accountability
              -   Enforcement of personnel rotation/rest periods
              -   Personnel monitored for stress/fatigue
              -   Changing environmental conditions are satisfactorily addressed
              -
          Team personnel will utilize the standard hand signals in the event of radio
           communication failure:

                  Hand gripping throat………..Out of air, can‘t breathe
                  Grip partners wrist or
                  both hands around waist…….Leave area immediately
                  Hands on top of head………..Need assistance
                  Thumbs up…………………….Ok, I am all right, I understand
                  Thumbs down…………………No, negative




11/05/10                                                                                  3-27
                                                                                  City of Seattle
                                                                 Seattle Fire Department (SFD)
                                                    _Metropolitan Medical Strike Team (MMST )

            An audible signals system (either hand held or originating from an apparatus)
             will be implemented to indicate a significant tactical change/need at the
             incident. These signals will indicate:

                -   ―Evaluate the Building‖ - 3 (three) consecutive 1-second blasts
                -   ―All Quiet or Stop Operations‖ – 1 (one) single 3-second blast
                -   ―Resume Operations‖ - 1 (one) single 3-second blast followed by 1
                    (one) single 1-second blast


            MMST management personnel must ensure that all personnel attend to
             personal hygiene requirements, including:

                -   Maintaining adequate hydration
                -   Washing their hands before eating and drinking

            Injury investigations/reports must be completed in a timely manner.


      (iv)       Post-incident:

            MMST personnel must identify and document appropriate issues at the
             conclusion of a mission. Safety considerations should be of paramount
             importance.

            The consolidation of this information should be conducted as soon as possible
             after the return home to ensure that detailed information is not lost.

            This information must be included into the mission After-Action Report and
             the lessons learned incorporated into strengthening:

                 - Operational procedures
                 - Equipment requirements
                 - Training and field exercises
                 -
            A critique/evaluation session should be conducted with all MMST personnel
             assigned to the mission to ensure that all facets of the mission receive
             attention.

            Recommendations specifically related to safety should be included in the
             After-Action Report. This should include a discussion of how improvement
             to existing practices and procedures can be made.




11/05/10                                                                                   3-28
                                                                                   City of Seattle
                                                                  Seattle Fire Department (SFD)
                                                     _Metropolitan Medical Strike Team (MMST )

           Critical Incident Stress Management sessions should be conducted for all
            MMST personnel.

           Actions should be take to ensure that all personal safety gear and equipment
            are inventoried and replaced in the cache.

           All reusable equipment items are to have a safety check conducted in
            accordance with manufacturer recommendations before being returned to the
                cache.


3.    Field Operations Overvie w

      (a)       Introduction

               The Field Operations Section will be composed of and supported by the
                following personnel:

                -   Operations Section Chief
                -   Field Medical Group Supervisor
                -   Field HazMat Group Supervisor
                -   Medical Specialist, Firefighter/Paramedic (12)
                -   Field HazMat Specialists (24)


      (b) Description of Duties for the Field Ope rations Section Personnel:

           (i) Perform Victim Rescue

               Normally, MMST members will not be involved in the actual rescue of
                victims from a confined space or other entrapment situation. However, in
                the event that the situation does occur, the activity in this regard will be
                coordinated in conjunction with the local HazMat Team/Fire Department.

               At no time are MMST members to unnecessarily jeopardize their lives
                while performing a rescue task.

               No rescue is to be attempted without appropriate PPE. The PPE
                appropriate to the situation will be determined by existing standard
                operating procedures (SOP‘S).

               Rescue attempts will not be initiated until decontamination is established.




11/05/10                                                                                    3-29
                                                                                    City of Seattle
                                                                   Seattle Fire Department (SFD)
                                                      _Metropolitan Medical Strike Team (MMST )

                 The MMST entry/rescue Team will initiate emergency decontamination
                  procedures on every patient they encounter before passing the patient off
                  to the Decontamination Team.

                 In a multiple victim scenario, ambulatory patients are to be removed first,
                  followed by near ambulatory patients, then unconscious patients.

                 The TFL will coordinate with the Law Enforcement Liaison and the
                  primary law enforcement agency, regarding the disposition of deceased
                  victims.


           (ii) Assist with Product Sampling and Identification

                 The Field Operations Section personnel will work with the local HazMat
                  Team representatives and other consultants in the immediate identification
                  of the product(s) by all available means possible.

                 Where appropriate, the Field HazMat Supervisor will designate team
                  personnel to don the appropriate level of personal protective equipment
                  (PPE) to perform reconnaissance work, including gathering secured
                  specimens that will be tested on site using available technology and/or
                  sent to local labs for further evaluation.


      (iii)       Perform Patient Decontamination

                 A decontamination alley with multiple lanes will be established as soon as
                  possible, upon arrival of the MMST, utilizing MMST members.

                 All decontamination equipment is to be functional before any personnel
                  make entry to perform a rescue and/or reconnaissance.

                 As a minimum, emergency decontamination will be performed on all
                  patients expected or known to be at risk for secondary contamination.


                 Decontamination will be performed in three stages. They are:

                  -   Emergency decontamination, which includes the removal of the
                      patient from a high-risk area, followed by clothing removal, then a
                      head-to-toe rinse with the appropriate solution (normally water unless
                      there is heavy metal involvement).




11/05/10                                                                                     3-30
                                                                                  City of Seattle
                                                                 Seattle Fire Department (SFD)
                                                    _Metropolitan Medical Strike Team (MMST )

               -   Secondary decontamination, which includes head-to-toe washing in a
                   systematic fashion using the designated decon solution specified by
                   Field HazMat, working in conjunction with the Field HazMat
                   Supervisor and HazMat Information Specialist, and followed by
                   rinsing with tepid water or normal saline.

               -   Definitive decontamination will be done by additional wash and rinse
                   to the point that no additional product is likely to be remaining on the
                   patient. This degree of decon will not normally be conducted in the
                   field, except under extraordinary circumstances. Rather, it will be
                   more routinely done as part of hospital decontamination.

              MMST personnel requiring emergency decontamination while working in
               the hot or cold zone will receive head-to-toe washing/ rinsing of the PPE
               followed by the removal of the suit in a fashion that is rapid and
               minimizes the risk of cross-contamination. The individual will be given a
               preliminary assessment and appropriate medical attention by personnel in
               the cold zone.

              While performing decontamination, reasonable attempts will be made to
               minimize cross-contamination spread.

              In cases of mass casualties, all reasonable efforts will be undertaken to
               decontaminate the exposed and/or injured using the most rapid and
               efficient practices possible.

              The airway will be cleaned first, then open wounds, and then the rest of
               the body in a systematic head-to-toe fashion.

              Scrubbing will be done utilizing the appropriate brushes and cleaning
               solution and in a fashion that does not lead to abrading or irritation of the
               skin.

              Rinsing will be done using tepid water temperatures (when available) and
               in a fashion that minimizes splash, skin irritation, or injury.

              During the decontamination process, decontaminated wounds are to be
               covered with an occlusive dressing.

              In situations involving multiple patients, or critically injured/ill patients,
               priority will be placed on performing emergency decontamination as soon
               as possible and, where clinically appropriate, administering the antidotes
               indicated for the condition before further decontamination is initiated.




11/05/10                                                                                   3-31
                                                                                  City of Seattle
                                                                 Seattle Fire Department (SFD)
                                                    _Metropolitan Medical Strike Team (MMST )

              Patients requiring a critical care procedure (e.g., intubation, IV, needle
               decompression, etc.) will be removed from the decontamination alley for
               the procedure to be performed safely and so as not to interfere with the
               decontamination process of remaining personnel.

              Critical care patients will not be taken care of at the expense of those less
               critically injured, except in the cases where an MMST member is
               involved.


       (iv) Provide Basic and Advanced Life Support to Disaster Victims

              Seattle's MMST medical personnel will not be a freestanding medical
               resource at the disaster site. Local medical systems will remain the
               primary providers of general medical care. However, team personnel will
               be utilized to attend to the needs of:

               -   MMST personnel and support staff
               -   Local responders
               -   Victims directly encountered by the MMST

              The Medical Specialists will be primarily responsible for rendering
               medical care under the direction of the Medical Director.

              The primary and secondary examination technique is to be utilized on all
               patients, with treatment emphasis on airway, breathing, and circulatory
               support.

              Seattle's MMST medical personnel involved with providing preliminary
               care will transfer patients as soon as possible to local authorities.

              Antidotes are to be administered according to the appropriate NBC
               medical treatment protocol (see Appendix I). All medications
               administered and other treatment rendered will be recorded.

              The Poison Control Center should be notified of the signs/symptoms being
               encountered and consulted for treatment options when needed.

              Deviation from medical protocols may be done only with the permission
               of the Medical Director.
              As soon as possible, the patients will be prepared for transport and their
               readiness reported.

              MMST personnel will retain information about any patient for whom they
               perform decontamination or administer medication. This will be do ne by


11/05/10                                                                                   3-32
                                                                                  City of Seattle
                                                                 Seattle Fire Department (SFD)
                                                    _Metropolitan Medical Strike Team (MMST )

                 removing the completed bottom portion of the triage tag from the patient
                 and/or quickly recording information about each patient. This information
                 will be necessary to maintain proper accountability for the patient
                 population encountered.


           (v) Assist Local HazMat Team with Incident Mitigation

                Field Operations Section personnel, working in conjunction with the local
                 HAZMAT team(s), will, to the extent necessary, assist with mitigation of
                 the incident by completion of one or more of the following practices
                 appropriate to the situation.

                 -   Diking
                 -   Damming
                 -   Neutralization
                 -   Vacuuming
                 -   Recontainerizing
                 -   Dilution
                 -   Enhanced dispersion

                Appropriate mitigation practices to be implemented will be the decision of
                 the Field Medical Group Supervisor in conjunction with the Field HazMat
                 Group Supervisor.

                Appropriate resources for the completion of mitigation procedures will
                 come from both the MMST equipment cache and local HazMat team
                 equipment and supplies.

                A record will be kept of all MMST equipment and supplies utilized during
                 the mitigation activity and given to the Logistics Specialist.



     (vi) Perform Additional Tasks and Duties as Assigned during the Mission

4.               Medical Considerations

                The Seattle Fire Department and the City of Seattle has long been
                 recognized as providing one of the finest EMS systems in the world. This
                 system consistently delivers superior service, the nations highest
                 resuscitation rates, two- minute response times throughout the City, and a
                 successful hospital control network that operates out of the Pacific
                 Northwest Level One Trauma Center, Harborview Medical Center.



11/05/10                                                                                   3-33
                                                                                    City of Seattle
                                                                   Seattle Fire Department (SFD)
                                                      _Metropolitan Medical Strike Team (MMST )

                The MMST is organized, staffed, and equipped to provide the best
                 possible pre-hospital and emergency medical care throughout the course
                 of an incident and especially on scene.

                MMST personnel are responsible for minimizing health risks and
                 incidence of Critical Incident Stress (CIS) syndrome.

                Medical personnel are responsible for providing the earliest possible
                 medical intervention for first responders and civilian victims of NBC
                 incidents through early identification of the agent type and proper
                 administration of the appropriate antidote(s) and other pharmaceuticals as
                 necessary.

                Personnel must be cautious about utilizing persons offering to assist in
                 medical management who claim to be physicians, nurses, or other medical
                 practitioners and who cannot substantiate their claims or provide adequate
                 credentials.

                Practitioners who provide credentials indicating that they have a medical
                 background should be assigned limited responsibilities in the cold
                 (support) zone commensurate with their area of medical expertise and in
                 an area working with a known team member.


(a) Treatment Priorities

                    The treatment priorities for field medical personnel (including field
                     medical members) are:

                    First, MMST personnel
                    Second, local response personnel who become ill or injured
                    Third, victims directly encountered by the MMST
                    Fourth, other injured/affected persons as practical



                    It is not the intent of the Team Medical Section or Field Medical
                     Section to be a freestanding medical resource at incident scenes.
                     However, they are part of the first line of intervention in a chain of
                     care that stretches to the local hospital medical system.


(b) Triage




11/05/10                                                                                      3-34
                                                                              City of Seattle
                                                             Seattle Fire Department (SFD)
                                                _Metropolitan Medical Strike Team (MMST )

               Triage is the process of doing the most good for the most victims. In
                NBC incidents, depending upon the purity of the agent, there may be
                few viable victims within the hot zone and increasing numbers of
                viable victims near the outer perimeter where the agent is less
                concentrated.

               Rapid medical intervention is indicated in exposures due to their
                immediate and sometimes irreversible effects on the patient.

               Victims should be triaged using the Seattle Fire Department's Simple
                Triage And Rapid Treatment (S.T.A.R.T.) System as the triage
                protocol. (For a more thorough explanation of the S.T.A.R.T. system,
                refer to Appendix J of this section.)


(c) Decontamination

               It is extremely important that victims of NBC agents receive, at a
                minimum, emergency decontamination prior to being transported to
                medical facilities.

               Patients that have completed on-scene emergency decontamination
                shall be identified with white flagging tape, preferably on an upper
                extremity.

               The degree of decon that has been performed and what solution was
                used should be noted on patient care forms (triage tags), which are
                attached to victims prior to transport.

               Definitive decon (a more intensive scrubbing/cleansing of patients)
                may have to be completed at receiving medical facilities; this should
                also be noted on the triage tags.

               Emergency decontamination procedures will be immediately initiated
                when MMST personnel are injured and/or have a PPE failure.

               Appropriate basic medical care will be initiated during decon and
                continued in the treatment section.
(d) Treatment

               Rapid patient assessment will be conducted on all victims.

               Medical intervention will be initiated following the MMST protocols
                found in Appendix I.



11/05/10                                                                               3-35
                                                                                  City of Seattle
                                                                 Seattle Fire Department (SFD)
                                                    _Metropolitan Medical Strike Team (MMST )

                  Particular medical attention is to be paid to airway/respiratory support
                   and cardiovascular support.

                  Medical care will address the supportive needs of each patient and the
                   specific treatment will be initiated when the agent is identified.

                  On-site treatment may include care for injuries sustained as a result of
                   explosions and/or falls.

                  Consideration must be given to the medical and logistical implications
                   of multiple doses of an antidote (ex., atropine) being given to a single
                   victim, thereby reducing the total number of patients that can be
                   treated effectively.

                  The Poison Control Center should be immediately notified of patient
                   problems being seen and used as a resource for product identification
                   and determining treatment regimens not covered by MMST protocols.


           (e) Casualty Collection Center (CCC)

                  If delay is encountered in transporting decontaminated victims,
                   consideration will be given to establishing a CCC to continue medical
                   treatment until transportation for victims is completed. Consider the
                   activation of a DMAT Team.

                  This area should be located as far away from the main operating area
                   of the incident as is possible and adjacent to the transportation section.

                  Priority for buildings designated for the CCC should target those
                   buildings with large auditoriums, showers and compartmentalized
                   rooms, (i.e. schools, office buildings, etc.).

                  Staffing should be the shared responsibility of the MMST and local
                   jurisdiction.

                  Equipment for the CCC will come primarily from the local
                   jurisdiction.

              Individuals who die while being treated at the CCC will be relocated to the
               designated temporary morgue site.

              The Law Enforcement Liaison will coordinate with the primary law
               enforcement agency to ensure proper evidence handling procedures are
               following regarding the deceased.


11/05/10                                                                                   3-36
                                                                                 City of Seattle
                                                                Seattle Fire Department (SFD)
                                                   _Metropolitan Medical Strike Team (MMST )




           (f) Emergency Transportation of Patients

1) Existing Ambulance Service

              The capacity for medical transportation in the City of Seattle includes:

           -   Fifteen (15) Seattle Fire Department aid/medic units; with both BLS and
               ALS capability;
           -   20 private ambulance units; with BLS capability only;
           -   City Metro Bus lines, single and articulated buses;
           -   City of Seattle School Buses


          There is a mutual aid mass casualty transportation plan. This plan
           incorporates county personnel and resources to move victims throughout the
           county. The countywide system includes:

           -   27 Fire Districts
           -   3 private ambulance companies



2) Onboard Staffing of Ambulance

          An effort will be made to transport all patients with the minimum of an ALS
           and BLS attendant. In the event of diminished resources, it may be required
           to staff with only two (2) BLS attendants, (EMT- level, minimum 100 hours of
           EMS training).

          The Seattle Fire Department will do all of the ALS transport, (Seattle-trained
           paramedics have received over 2000 hours of training under the direction of
           the Hospital Control Medical Director, through the University of
           Washington‘s School of Medicine).


3) Augme ntation to Handle Mass Casualties

          In the event of an incident, local fire resources are utilized on-scene. Once
           these resources are depleted, a countywide mutual aid system is implemented,
           to include:

           -   27 Fire Districts
           -   3 private ambulance companies


11/05/10                                                                                  3-37
                                                                                 City of Seattle
                                                                Seattle Fire Department (SFD)
                                                   _Metropolitan Medical Strike Team (MMST )




4) Integrate Ambulance Service into the MMST Response

                         Patient transportation is a part of the existing incident command
                          system and structure. The MMST will be integrated into the
                          ICS structure and the mass casualty procedures. Within this
                          structure:

                          -   The Incident Commander will assign a triage, treatment and
                              transportation officer.

           -   The MMST Hospital Liaison Officer will interface with these three ICS
               components and, in coordination with the MMST Medical Director, will
               develop the transportation plan for the incident.


5) Medical Treatment Requirements Enroute to Hospital

        Medical personnel will be working under current Seattle Fire Department field
         medical instructions and directed by the Hospital Control Medical Director,
         (who is also the MMST Medical Director).


6) Decontamination Require ments for Patient Trans portation Vehicles

          Patients will be decontaminated prior to transport.

          At the conclusion of the incident, MMST and local fire department hazardous
           materials personnel will bring all vehicles used for patient transportation to a
           designated collection point, (as determined by the IC) for evaluation.

          Any vehicle knowingly used to transport a contaminated patient will be
           immediately placed out-of-service and brought to the collection point for
           evaluation.

          First responders that occupied a contaminated vehicle must be decontaminated
           and evaluated for treatment.


               vii.   Transportation

                         Transportation of victims who are unconscious must be by an
                          emergency vehicle capable of continuous treatment and
                          emergency response to the medical facility.


11/05/10                                                                                  3-38
                                                                                City of Seattle
                                                               Seattle Fire Department (SFD)
                                                  _Metropolitan Medical Strike Team (MMST )



                         Public transportation vehicles staffed with an appropriate
                          number of local EMS personnel can transport large numbers of
                          victims who are minimally affected or who are suspected of
                          having psychosomatic symptoms.

                         MMST personnel arranging for transportation must keep in
                          mind that vehicles used for transport may become
                          contaminated; that fact should be borne in mind when
                          obtaining public transport vehicles. Vehicles and personnel
                          used for transport that become contaminated must be
                          decontaminated before returning to service.


5.         Hospital Eme rgency Medical Services

(a) Integration into the Incident Command System

                     The Hospital Emergency Medical Services and the MMST System
                      will be integrated into the City of Seattle‘s Disaster Plan and
                      Incident Command Structure.

                     Local hospitals are being encouraged to enhance their procedures
                      and plans for accommodating WMD mass casualties into the
                      hospital system. These issues include:

                      -   Lock down procedures
                      -   Providing PPE and NBC agent identification for all hospital
                          personnel
                      -   The ability to increase the number of security staff without
                          delay. The security staff must be equipped with PPE and
                          trained in NBC agent identification.
                      -              Develop portable exterior triage and
                          decontamination stations. These stations would prevent the
                          hospitals and their emergency rooms from becoming
                          contaminated from self-referral patients.

                     This effort would be coordinated with the Casualty Collection
                      Center (CCC) sites established near the incident by the MMST.
                      Priority for buildings designated as Casualty Collection Centers
                      would target those buildings with large auditoriums, showers, and
                      compartmentalized rooms.


(b) Pharmaceuticals


11/05/10                                                                                 3-39
                                                                                 City of Seattle
                                                                Seattle Fire Department (SFD)
                                                   _Metropolitan Medical Strike Team (MMST )



                     The Seattle Fire Department‘s MMST Team will initially carry
                      pharmaceuticals to treat first responders and critical patients.

                     The Hospital Control Medical Director will be coordinating the
                      accessing of pharmaceuticals from commercial and military
                      vendors, based on needs. These pharmaceuticals will be brought to
                      distribution points by public safety officials under the direction of
                      the Incident Commander.




(c) Pre-stocked NBC Pharmaceuticals

          The Fire Department‘s first responder medical units will carry limited stores
           of WMD/NBC medicines. The MMST will maintain a larger inventory of
           WMD/NBC medicines. Local hospitals are being encouraged to increase
           their stocks of pre- identified pharmaceuticals. Hospital Control will be
           contacted for pharmaceutical needs. There are pre-designated commercial and
           military sources outside of the MMST System but within the Seattle-area for
           pharmaceutical replenishing.

(d) Transportation Plan

          The transportation plan, in addition to the Seattle Fire Department‘s first
           responder medical units, has 35 ambulances capable of patient transport.
           There are pre- identified transportation vehicles available for ambulatory
           patients within the public and private sector for mass transit capability.
           Additional assets are available by requesting mutual aid, government and
           military support for patient transport vehicles.


(e) Hospital Selections/Destinations

          The selection system for patient destination is coordinated and controlled by
           the Hospital Control Medical Director.



(f) WMD Medical Treatment Protocols

          Each of the receiving hospitals will be operating under agreed upon WMD
           treatment protocols as established by the Hospital Control Medical Director,


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                                                                                  City of Seattle
                                                                 Seattle Fire Department (SFD)
                                                    _Metropolitan Medical Strike Team (MMST )

           the Seattle/King County Medical Director and the Director of Seattle/King
           County Public Health.

          A countywide mutual aid response will support continued patient care at the
           incident site through transport to and treatment at regional medical facilities.

(g) Decontamination Capability

          The incident action plan includes the establishment of a large perimeter to
           contain potentially contaminated patients and restrict access to the incident
           site, thus avoiding further contamination. Emergency decontamination will be
           implemented simultaneously with the establishment of hot, warm and cold
           zones. Decontamination corridors will be established.

          It is anticipated a large number of walk- in non-transported patients will
           require decontamination PRIOR to them entering the hospitals. Therefore, the
           Seattle Fire Department will be prepared to assist in the planning and
           implementation of exterior emergency decontamination corridors at area
           hospitals.

          The Seattle Fire Department will deploy their decontamination trailer to the
           incident site for secondary (definitive/technical) decontamination capability,
           (the system affords specific decontamination solutions, warm water and
           privacy). The goal is to provide this level of decontamination to patients prior
           to being transported to minimize the possibility of cross contaminating
           transport resources and personnel.

           -   This trailer may also be deployed to local hospitals as a remote technical
               decontamination station, supplementing the exterior emergency
               decontamination, if needed.

6.             Forward Movement of Patients

(a) Extension of Existing NDMS Patient Transportation and Treatment

          After the local resources are expended, the City of Seattle‘s Emergency
           Operations Center will access state resources, which can then access federal
           resources. There currently exist a local, regional and federal disaster response
           plan. These plans would be exercised upon notification of the event.


(b) Adaptation to a Mass Casualty Situation

                  There is a mass casualty plan that would be implemented once the
                   event is made known. The plan exists in the City of Seattle‘s Disaster


11/05/10                                                                                   3-41
                                                                                 City of Seattle
                                                                Seattle Fire Department (SFD)
                                                   _Metropolitan Medical Strike Team (MMST )

                  Readiness and Response Plan, the Seattle Fire Department Operating
                  Instructions and the Seattle Police Departments Policies.

          There are pre-established shelter areas and designated Points of Departure,
           (POD) (such as Boeing Field or Seatac International Airport) that will be
           exercised in the event of a mass casualty incident.

          There is a Seattle-based DMAT team, available once federal assets are
           authorized.




(c) Integration into the MMST System Response

          The MMST system and resources will be integrated into the functioning
           incident command system and the mass casualty plans at the event.

7.    Mental Health Services

(a) Mental Health Service in a Mass Casualty Situation

          The incident commander will activate the Emergency Operations Center.
           Within the EOC, the Health and Hospital ESF-8 Coordinator (see chart on
           page 3-5) would make available to the Incident Commander local and regio nal
           mental health professionals for treatment. The ESF-8 Coordinator would
           ensure the development of the mental health treatment plan.


(b) Mental Health Services for First Responders

          A joint CISM system exists for Police and Fire responders. It is staffed with
           police psychologists and a team of trained Police and Fire personnel. The
           incident commander, 9-11-dispatch center, or any ranking officer that
           identifies the need can access it.
          As per latest draft copy of Seattle and King County ESF-8, the Emergency
           Medical Services Division of the Health Department will coordinate with the
           SPD, SFD, and the Washington CISM Net to provide Critical Incident Stress
           Debriefing services for emergency service workers after the disaster.


(c) Mental Health Services for Victims, Families and the Local Community




11/05/10                                                                                  3-42
                                                                                       City of Seattle
                                                                      Seattle Fire Department (SFD)
                                                         _Metropolitan Medical Strike Team (MMST )

                  The ESF-8 Coordinator will develop an overall strategy for providing
                   mental health counseling to the affected community.

                  The Health Department will coordinate with King County Department of
                   Human Services, Mental Health Division and the American Red Cross to
                   provide crisis response and mental health services for persons who suffer
                   from reactions to the disaster.

                  The Mental Health Division will provide mental health crisis response and
                   involuntary detention services and outpatient mental health services for
                   persons who suffer from reactions to the disaster.

                  The American Red Cross will provide disaster mental health services to
                   citizens as outlined in ARC Disaster Services Regulations and Procedures,
                   per volunteer staffing allowances.

                  In accordance with King County ESF-8, the mental health components are
                   meeting to improve the existing response plan. The community Psychiatric
                   Clinic has a number of treatment sites in the Seattle-area offering crisis
                   intervention, individual and family counseling. They can be accessed
                   through the State EOM as part of the Community Education Program under
                   the State Mental Health Division.

                   Federal Resources can be accessed through FEMA and NDMS.

                   All aid and medic units carry referral cards for mental health assistance, to
                    be provided to the general public, as needed.


(d) Integration into the MMST System Response

                   The ESF-8 portion of the EOC will operate within the ICS structure during
                    the incident.


8.    Plans for Disposition of Non-Survivors

(a) Based on Existing Mortuary Se rvice

              The Seattle/King County Medical Examiner will be the lead for the
               development of a temporary morgue site(s) and developing the plan for the
               disposition of the deceased. The Seattle/King County Medical Examiner will
               work under the direction of law enforcement.




11/05/10                                                                                        3-43
                                                                                   City of Seattle
                                                                  Seattle Fire Department (SFD)
                                                     _Metropolitan Medical Strike Team (MMST )

(b) Adaptation to a Mass Casualty Situation

           The mechanism for dealing with a mass casualty incident is included in the
            Mass Casualty Incident Plan. A priority for resources will be to control access
            to the non-survivors until the incident has stabilized.

            -   Resources needed to properly decontaminate the non-survivors will be
                identified during this phase of Operations.


(c) Crime Scene Considerations

           Law Enforcement and the King County Medical Examiner will be responsible
            for the official determination of the time and cause of death.

           The Seattle Police Department bomb technicians will support initial evidence
            collection and the handling of explosive devices.

           Decontamination of non-survivors may be facilitated under the
            direction/assistance of military/federal assets, which may include:

                   -    A DEMORT Team.


(d) Integration into the MMST System Response

           The Seattle/King County Medical Examiner will work within the framework
            of the on-site Incident Command System.


9.      Planning Conside rations

     (a) Introduction

        The Planning Section is responsible for the collection, evaluation, dissemination
               and use of information about the development of the incident and status of
               resources. Information is needed to:

           Understand the current situation
           Predict probable course of incident events, and
           Prepare alternative strategies and control operations for the incident


            (b) Description of duties for the Plans Section include:



11/05/10                                                                                    3-44
                                                                                  City of Seattle
                                                                 Seattle Fire Department (SFD)
                                                    _Metropolitan Medical Strike Team (MMST )

          Collect and process situation information about the incident

          Supervise preparation of the MMST Incident Action Plan

          Establish information requirements and reporting schedules

          Determine need for any specialized resources in support of the incident

          Establish special information collection activities as necessary, e.g., weather,
           environmental, toxins, etc.

          Assemble information on alternative strategies

          Provide periodic predictions on incident potential

          Report any significant changes in incident status

          Compile and display incident status information

          Oversee preparation and implementation of the Incident Demobilization Plan

          Incorporate plans, (e.g., Traffic, Medical, Communications) into the Incident
           Action Plan

          Maintain MMST Log



10.   Logistical Considerations

           (a) Introduction

              The Logistics Section will be composed of a Logistics Section Chief, a
              Logistics Group Supervisor, four Logistics Specialists, a Communications
              Group Supervisor and a Communications Specialist. The Logistics Section is
              responsible for providing facilities, services, and material in support of
              MMST Operations.


           (b) Description of Duties for Logistics Personnel include the following:

          Assures maintenance of the equipment cache in state of readiness for immediate
           deployment

          Assures cache gets to the designated mobilization point or incident location


11/05/10                                                                                   3-45
                                                                                    City of Seattle
                                                                   Seattle Fire Department (SFD)
                                                      _Metropolitan Medical Strike Team (MMST )



             Assures procurement of non-cache items during the mobilization phase or on site
              as appropriate

             Assists with all distribution of needed medical equipment and pharmaceuticals
              from designated local and regional facilities in coordination with MMST Hospital
              Liaison

             Maintains appropriate records and reports

             Participates in the development of Incident Action Plan

             Identify service and support requirements for planned and expected operations

             Coordinate and process requests for additional resources

             Advise on current service and support requirements

             Estimate future service and support requirements

           Establishes and maintains communications capability for MMST Operations

          (c) Communications

   (i)        Considerations

                 Effective communication is vital to the safe and successful operations of a
                 MMST assigned to a mission. The following procedures are identified to
                 promote standardization:

                    MMST Designations
                    Communications Procedures Between Team Members


   (ii)       MMST Designations

                    Each MMST will be identified by a unique radio call sign. The call
                     sign will incorporate the State of origin of the MMST and a number to
                     differentiate each MMST from that State.

                    For example, DC MMST One will be used to identify the first MMST
                     developed for the MMST concept. This would be denoted as DC-1 for
                     written correspondence.



11/05/10                                                                                     3-46
                                                                                City of Seattle
                                                               Seattle Fire Department (SFD)
                                                  _Metropolitan Medical Strike Team (MMST )

                The following MMST designations will identify the currently accepted
                 MMSTs sponsored by the listed organizations:

                  DC-1 Metropolitan Washington Area Council of Governments
                  GA-1 Atlanta Area Police and Fire Departments
                  WA-1 Seattle Metropolitan Medical Strike Team


   (iii)   Communications Procedures

                Team members (except entry teams) will communicate on the
                 operational channel assigned upon arrival at the incident site.

                Entry teams, if used, will operate on the operational channel assigned
                 them prior to making entries.

                It is permissible for members to monitor the entry team channel, but
                 they will not transmit on that channel(s) unless there is an emergency
                 situation that requires the entry team be immediately notified. That
                 notification should originate from the entry team section leader, but
                 may originate from anyone detecting the emergency situation.

                Entry teams will communicate directly with the Field HazMat Group
                 Supervisor who will communicate with the Operations Section Chief
                 on the primary operational channel.

                The Safety Officer can monitor the channels as he/she feels
                 appropriate for the specific situation, but will use the primary
                 operational channel for routine interteam communications.

                Section leaders will use the primary operational channel for routine
                 interteam communications.

                The TFL will operate on the primary operational channel for
                 communications with team members.

                The TFL will operate on the local jurisdiction's frequency (patched in)
                 when it is necessary to communicate electronically with the Incident
                 Commander (IC) or Command Post.

                The Plans Section Chief will communicate within the team on the
                 primary operational channel and will coordinate communications to
                 organizations and facilities outside the geographic incident area (e.g.,
                 Centers for Disease Control (CDC), local area poison control centers,
                 etc.).


11/05/10                                                                                 3-47
                                                                                  City of Seattle
                                                                 Seattle Fire Department (SFD)
                                                    _Metropolitan Medical Strike Team (MMST )



                   The Hospital Liaison will communicate within the team on the primary
                    operational channel and will coordinate communications to medical
                    facilities within the incident geographic area (e.g., local hospitals,
                    medical facilities, etc.).

11.      Law Enforce ment Considerations

             (a) Introduction

                It is recognized that law enforcement will provide only one LEL
                (Lieutenant or higher) and an Intelligence Information Specialist (sergeant
                or higher) as MMST members. Any additional law enforcement personnel
                (i.e. bomb technicians, SWAT, etc.) are considered resources, but not team
                members.

                The use of additional law enforcement resources may be required at an
                NBC incident, see Chapter 6 ―Law Enforcement Function‖ for specifics.
                It is agreed that law enforcement personnel will not be required to work in
                known contaminated areas without the proper personal protective
                equipment.


(b) Description of D uties for MMST Law Enforcement Liaison and Law
    Enforce ment Intelligence Information Specialists include:

            Gather and disseminate intelligence information, as appropriate

            Coordinate with the local FBI office

                   Assist and coordinate with the primary enforcement agency as
                    appropriate, regarding: MMST and scene security, traffic and crowd
                    control, evidence preservation and criminal investigation.

B.       POSITION DESCRIPTIONS AND OPERATIONAL CHECKLISTS

                                       INTRO DUCTION


          The Seattle Fire Department used the United States Public Health
      Service/Office of Emergency Prepare dness (USPHS/OEP) Metropolitan Medical
      Strike Team (MMST) position descriptions and operational checklists as a
      guideline and criteria for attaining operational capability. The purposes of
      MMST operational checklists are to define the duties and responsibilities of the
      respective MMST positions during a mission assignment. The list is intended to
      be a general summary of actions. The following should be understood:



11/05/10                                                                                   3-48
                                                                                 City of Seattle
                                                                Seattle Fire Department (SFD)
                                                   _Metropolitan Medical Strike Team (MMST )



              Some required actions may not be listed within these checklists, but must
               be identified and assumed by the MMST positions.

              Some actions may be the primary responsibility of another MMST
               position, but may require assistance and coordination from this position.

              The actions are listed in a general chronological order, but may necessitate
               deviation as necessary.

           An important precept of the MMST is for all members to be sufficiently cross-
           trained in alternate functional capabilities to ensure depth of capability and
           integrated MMST operations during missions.

       The MMST was developed to provide support for, and to provide assistance to,
   local jurisdictions' first responders in nuclear, biological, or chemical (NBC) events.
   This is accomplished by coordinating with the Incident Commander (IC) to determine
   how the MMST can be utilized in the incident. The MMST has a strong emergency
   medical care focus and has the capability to provide rapid and comprehensive medical
   intervention to casualties of NBC events. Response personnel involved in these
   incidents must remember that, with the proper agent and near perfect dissemination,
   the number of casualties will be high and the entire event may persist from hours to
   several days, from initial response to completion of facility decontamination and
   certification of re-occupancy.

   Jurisdictions needing the MMST will make their request for assistance through their
   local emergency communications center. The Program Director will then decide the
   appropriate response to the request, in turn activating the on-call MMST and
   determining the mobilization point(s) to which MMST members should report.

   When the MMST is activated, the TFL will ensure notification of the Seattle
   Emergency Operations Center (EOC). The Seattle EOC will notify the appropriate
   State and Federal agencies. Federal agencies responding to the incident and/or
   reporting to the incident site will need to assimilate into the incident in a coordinated
   fashion to provide assistance in their respective area of expertise.

   Upon arrival at the incident scene, the TFL will coordinate with the jurisdiction IC to
   determine how the MMST can optimally provide assistance. The MMST will locate
   proximal to the Incident Command Post and begin initiating the activities and
   functions necessary to support successful incident mitigation.

   Incident Commanders must be prepared to coordinate the efforts of many agencies,
   entities, and disciplines: additional local HazMat Teams, State resources, and Federal
   resources. The command system must truly be a unified command. At some point
   after all viable patients have been removed from the hot zone, and offensive


11/05/10                                                                                  3-49
                                                                                  City of Seattle
                                                                 Seattle Fire Department (SFD)
                                                    _Metropolitan Medical Strike Team (MMST )

   operations have ceased, the Federal Bureau of Investigation (FBI) will assume
   responsibility for incidents of a terrorist nature. Their role is the recovery of evidence
   and the investigation of the overall incident. This activity may require the support of
   the local jurisdiction's personnel as well as the MMST. The transition from local
   control and command to Federal control and command must be made smoothly, with
   all participants knowing their roles and responsibilities in both scenarios.

   Once the Attorney General has determined a crisis no longer exists and the FBI has
   completed their on-site investigation, cleanup of the facility will be coordinated as a
   part of the consequence management efforts under the direction of FEMA. MMST
   members will gather their equipment, ensuring that contaminated expendables have
   been containerized in preparation for disposal. The IC, in coordination with the TFL,
   will determine when the MMST can return to service and depart the incident scene.




11/05/10                                                                                   3-50
                                                                                                                                        City of Seattle
                                                                                                                       Seattle Fire Department (SFD)
                                                                                                          _Metropolitan Medical Strike Team (MMST )


                                                  Seattle Fire Department

                          METRO MEDICAL STRIKE TEAM       (Proposed 62 Person Team)




                                                                  TFL
                                              Law Enforcement                     Safety
                             Security             Liaison                         Officer


                                                  Medical                       Hospital
                                                  Director                      Liaison



              OPERATIONS                        PLANS                                       LOGISTICS                        TEAM-MEDICAL
               SECTION                         SECTION                                       SECTION                           SECTION
                CHIEF                           CHIEF                                         CHIEF                             CHIEF


 Field-Medical (FM)     Field-HazMat (FH)        Plans                  Communications                   Logistics                  TM - Unit 1
       Group                  Group             Group                       Group                         Group                    1 Unit Leader
     Supervisor             Supervisor         Supervisor                 Supervisor                    Supervisor                  1 Specialist

                                                                                                                                    TM - Unit 2
         FM - Unit 1           FH - Unit 1         Intelligence                  Comm Unit                 Log. Unit 1             1 Unit Leader
       1 Unit Leader         1 Unit Leader       Info - Specialist               1 Specialist             1 Unit Leader             1 Specialist
        5 Specialists         5 Specialists    (Law Enforcement)                                           1 Specialist

         FM - Unit 2           FH - Unit 2           HazMat                                                Log. Unit 2
       1 Unit Leader         1 Unit Leader       Info - Specialist                                        1 Unit Leader
        5 Specialists         5 Specialists         (Chemist)                                              1 Specialist

                               FH - Unit 3           Medical
                             1 Unit Leader       Info - Specialist
                              5 Specialists       (Toxicologist)

                               FH - Unit 4
                             1 Unit Leader
                              5 Specialists
11/05/10                                                                                      3-51
                                                City of Seattle
                               Seattle Fire Department (SFD)
                  _Metropolitan Medical Strike Team (MMST )




11/05/10   3-52
                                                                                    City of Seattle
                                                                   Seattle Fire Department (SFD)
                                                      _Metropolitan Medical Strike Team (MMST )



I. COMMAND GROUP

       A) Task Force Leader (TFL)

      (1) Introduction

           The central point of coordination of the MMST is the Task Force Leader
           (TFL). This position must blend the different disciplines within the Team into
           an integrated unit during an event. The TFL must also receive information
           from local agencies, DoD, USPHS, and other sources; implement strategic
           and tactical assignments; and provide the necessary information flow for
           proper event management.

           It is imperative that the MMST becomes an integral part of the existing local
           command structure upon arrival at the incident location. The TFL should be
           prepared to integrate into different variations of the Incident Command
           System (ICS) that may be implemented by the local jurisdiction. It should be
           clearly understood by the local jurisdiction command and control staff that the
           MMST is a resource that is available for their use and under their operational
           direction. This interaction must be conducted in a cooperative manner.

           The TFL is responsible for managing and supervising all Team activities
           during a mission assignment. The TFL reports directly to the MMST Program
           Director (Seattle Fire Department Assistant Fire Chief).


      (2) The TFL pe rforms the following duties:

              Addresses the coordination and supervision of all MMST activities

              Receives notification of an event

              Initiates the emergency callback of the appropriate MMST personnel

              Initiates State and PHS notification

              Supervises the following positions:

                  MMST Command Staff
                   Law Enforcement Liaison
                   Safety Officer
                   Medical Director
                   Hospital Liaison



11/05/10                                                                                     3-52
                                                                                  City of Seattle
                                                                 Seattle Fire Department (SFD)
                                                    _Metropolitan Medical Strike Team (MMST )

                      General Staff
                       Field Operations Section Chief
                       Plans Section Chief
                       Logistics Section Chief
                       Team Medical Section Chief

              Possesses flexibility to be available to mobilize on short notice

              Possesses knowledge of the Federal Response Plan (FRP) and how the
               MMST mission fits into that plan

              Possesses a comprehensive knowledge of MMST functions, operations,
               tactics, strategy, and safety considerations

              Possesses strong interpersonal relations skills

              Possesses competency in the development and use of integrated action
               planning concepts and processes

              Possesses good interagency coordination skills and the ability to work well
               with various technical components and other organizations

              Possesses ability to communicate effectively orally and in writing

              Possesses knowledge of the practical application of available technology
               used to support MMST missions and objectives

              Possesses ability to be flexible, to improvise, share information, resolve
               conflicts, and solve problems

              The TFL has proven expertise at providing decisive and innovative
               administrative and incident management and:

           -   Ensures adherence to all safety procedures
           -   Is responsible for the determination of all MMST organizational needs
           -   Interacts with the USPHS liaison for coordination of all MMST support
               requirements
           -   Receives briefing and situation reports and ensures that all MMST
               personnel are kept informed of status changes
           -   Coordinates with the local Incident Commander or designee during an
               event




11/05/10                                                                                   3-53
                                                                                  City of Seattle
                                                                 Seattle Fire Department (SFD)
                                                    _Metropolitan Medical Strike Team (MMST )

   (3) Operational Checklist

      (a) Prior to activation:

           Coordinates team readiness with the MMST Program Director (Seattle Fire
           Department Assistant Fire Chief)

           Coordinates crisis management activities with appropriate officials

           Develops preliminary response plan based upon available intelligence

           Ensures personal ''GO'' kit is available and complete


      (b) Upon activation:

           Receives notification of assignment and details of the event (as known) from
           the initiating organization

           Ascertains suitable mobilization site recommendation from Incident
           Commander

           Determines if mobilization and deployment are appropriate

           Determines the mobilization site to be used

           Initiates the MMST emergency mobilization procedure

           If possible, determines exact incident location, site conditions, magnitude of
           incident, prevailing endemic conditions, likely resources required, and
           mobilization site (i.e., fire and police stations, schools, etc.)

           Determines, as well as possible, if the event is a single or multiple site
           incidents. This information will weigh heavily in the decision to split the
           Team for response to multiple sites

           If a multiple site response is required, consideration should be given to
           activating additional MMST members to respond to these sites

           Due to the magnitude of the event, particularly if there are multiple sites
           involved, the Team or pertinent members of the Team may stage in a central
           location to provide technical advice to each of the affected sites

           Monitors disaster-related information from local sources




11/05/10                                                                                   3-54
                                                                                 City of Seattle
                                                                Seattle Fire Department (SFD)
                                                   _Metropolitan Medical Strike Team (MMST )

           Disseminates appropriate information to the appropriate section officers

           Coordinates with the primary law enforcement agency through the Law
           Enforcement Liaison regarding security concerns of the medical cache, as
           appropriate


      (c) At mobilization site:

           Makes a determination of the appropriate allocation of personnel.

           Ensures that section officers are adequately briefed on and understand the
           following incident details including:

              Site location
              Units currently operating on site
              Actions taken to date (as far as can be determined)
              Agent involved (as far as can be determined)
              Number of persons involved (casualties and non-casualties)
              Probable mission objectives and assignments

           Affixes appropriate functional identifier

           Brings personal ''GO'' kit


      (d) In transit:

           Reviews latest information as it becomes available

           Reviews TFL checklist

           Assures all members review information pertinent to their position description

           Assures anticipated logistical requirements (i.e., PPE, decon requirements,
           communications protocols, medical care issues) are met

           Confirms medical cache and decon trailer(s) are enroute

      (e) On-site ope rations:

           Locates Incident Command Post and coordinates with the IC. (If no Incident
           Command System (ICS) has been established, it would be prudent at this time
           to establish one with a designated IC.)



11/05/10                                                                                  3-55
                                                                                  City of Seattle
                                                                 Seattle Fire Department (SFD)
                                                    _Metropolitan Medical Strike Team (MMST )

           Determines the operating area for the MMST

           Assures that the communications personnel are establishing communications
           linkages

           Determines mission objectives and relays them to section officers

           Assesses the need for additional resources or Teams (Technical Escort Unit,
           Chemical Biological Defense Command, National Guard, etc.) and assists in
           obtaining their help

           Ensures that each section leader has established an operating area and is
           coordinating with the appropriate personnel

           Works with IC to identify and address strategic and tactical issues

           Assures all MMST members wear their appropriate functional identifiers

           Ensures ongoing MMST needs are identified and met

           Determines work schedules, rest and rotation periods

           Ensures personal physical readiness through proper nutrition, water intake,
           rest, and stress control techniques

           Evaluates MMST operations; modifies as appropriate:

              Assesses effectiveness of overall strategy and tactics
              Assesses and meets equipment shortages
              Ensures health/welfare needs of personnel are met
              Assesses for fatigue
              Assesses for signs of Critical Incident Stress
              Ensures adherence to established procedures

      Ensures incident logs are being properly maintained

      Works with Poison Control Center to address public information issues


      (f) Demobilization:

           Determines the continued need for the MMST and if no further need is
           identified, recommends to the IC that the team be returned to service




11/05/10                                                                                   3-56
                                                                                  City of Seattle
                                                                 Seattle Fire Department (SFD)
                                                    _Metropolitan Medical Strike Team (MMST )

           Assigns members to assist in the decontamination breakdown and repacking
           of equipment, supplies, and materials to return to the equipment cache

           Ensures arrangements for transportation home are made

           Ensures After-Action report data gathering is instituted

           Identifies the need for an after-action Critical Incident and Stress Management
           (CISM) defusing/debriefing


      (g) Post-incident:

           Reports his/her ill or unusual feelings or sicknesses that may be attributable to
           exposure at the incident to the Team Medical Section Chief

           Initiates a critical review of team performance

           Initiates arrangements for CISM defusing/debriefing

           Initiates After-Action report

           Assures that the MMST cache is returned to deployment status

           Restores personal ''GO'' kit to deployment status

           The TFL will make contact with their employing agency to inform them of the
           termination of their participation in MMST activation and follow the time and
           attendance reporting requirements of their home jurisdiction.

B) Law Enforcement Liaison

   (1) Introduction

      A Police Officer, usually of Lieutenant rank or higher is the Law Enforcement
      Liaison of the MMST.


   (2) The Law Enforcement Liaison coordinates or performs the following duties:

      (a) Intelligence: An important activity that may provide information to the TFL in
          the following areas:




11/05/10                                                                                   3-57
                                                                                  City of Seattle
                                                                 Seattle Fire Department (SFD)
                                                    _Metropolitan Medical Strike Team (MMST )

          Sufficient advance warning of a potential nuclear, biological, or chemical
           (NBC) emergency within the MMST sponsoring jurisdiction by obtaining
           information from a variety of sources:

              -   Develop and maintain a working relationship with the local FBI Field
                  Office and an awareness of the resources that can be utilized in an
                  NBC incident

              -   Develop and maintain a working relationship with all law enforcement
                  agencies, regardless of size, within the sponsoring jurisdiction and an
                  awareness of the resources that can be utilized in an NBC incident

              -   Develop and maintain a working relationship with the local Public
                  Health Official and an awareness of the resources that can be utilized
                  in an NBC incident

              -   Develop and maintain a working relationship with the local fire and
                  rescue agencies (including HAZMAT elements) and an awareness of
                  the resources that can be utilized in an NBC incident

              -   Develop and maintain a working relationship with such local
                  Emergency Operations Centers as may be available (both civilian and
                  military)

              -   Attend regularly any local area intelligence sharing forums, both
                  formal and informal

              -   Develop and maintain a working knowledge of agent precursor
                  information including but not limited to local manufacturer, storage,
                  and retail sources of precursors

              -   Keep up-to-date on national and international events and/or groups by
                  any media available (print, television, Internet, police teletype, etc.), in
                  accordance with the City of Seattle Ordinance #108333, ―Collection of
                  Information for Law Enforcement Purposes.‖

              -   Is responsible for the gathering and dissemination of all information
                  pertinent to MMST security issues

              -   Will develop procedures to regulate the flow of ―classified‖
                  information within MMST command and general staff personnel, as
                  appropriate

              -   Coordinates security issues with the Plans Section Chief and the Task
                  Force Leader



11/05/10                                                                                   3-58
                                                                                 City of Seattle
                                                                Seattle Fire Department (SFD)
                                                   _Metropolitan Medical Strike Team (MMST )



               -   Coordinates with Seattle Police or other law enforcement resources, to
                   support MMST mission (e.g. SWAT, Explosives, etc.)

              Sufficient knowledge of resources within the MMST sponsoring
               jurisdiction in order to advise the Incident Commander (IC) of an affected
               jurisdiction during an NBC incident (through the TFL) in the following
               areas:

               -   Resources that are available to the IC from the local area

               -   Intelligence information that may be applicable to the NBC incident

               -   Incident Command System (ICS) management capabilities consistent
                   with any area provisions or standing agreements

               -   Evidence control procedures required as the result of an NBC incident,
                   as determined by the primary law enforcement investigative unit


      (b) Team Security: The Law Enforcement Liaison will assist the TFL and will
          coordinate with the primary law enforcement agency in the following areas:

            Determine a safe mobilization area

            Map out the safest and most direct route to the incident scene from the
             established mobilization area

            Determine the location of the incident scene command post and staging
              area from the IC of the incident scene

            The response to the injury of an MMST member during a deployment to
              include:

               -   Assist in arranging for transport of family members to the hospital of
                   the injured person

               -   Make notification of the employing agency of the injured MMST
                   member

      (c) Scene Security and Evidence Control: Will assist and coordinate with the law
          enforcement agency of the affected jurisdiction in order to provide advice on the
          following:




11/05/10                                                                                  3-59
                                                                                  City of Seattle
                                                                 Seattle Fire Department (SFD)
                                                    _Metropolitan Medical Strike Team (MMST )

              Coordination with the senior law enforcement official of the affected
               jurisdiction at the incident scene for any special access requirements
               (obtaining special passes, escorts, etc.) for MMST members at the incident
               scene.

               -   Advise all MMST components of these requirements

               -   Act as liaison with the law enforcement agency of the affected
                   jurisdiction responsible for perimeter security at the incident scene to
                   facilitate the arrival and departure of MMST members and equipment
                   through the perimeters

              Inner Perimeter locations

              Outer Perimeter locations

              Considerations regarding traffic flow and the rerouting of traffic near the
               incident scene

              Assist and coordinate with the primary law enforcement agency regarding
               evidence procedures which may include:

               -   Mapping of all evidence locations

               -   Collection of all contaminated evidence once that evidence has been
                   made safe

               -   Collection of all non-contaminated evidence, such as logs, video/audio
                   recordings, notes, etc.

               -   Establishment of a chain of custody procedure with the ultimate aim of
                   turning evidence over to the FBI or the law enforcement agency of the
                   affected jurisdiction

               -   Items of evidence that cannot be made safe should be filmed,
                   photographed, etc., before being turned over to the agency responsible for
                   mitigation of the contaminated material at the incident scene.


      (d) Weapons Policy

          Law Enforcement Liaison will assist the Task Force Leader in establishing
           appropriate weapons‘ policies and procedures for non- law enforcement
           personnel.



11/05/10                                                                                   3-60
                                                                                  City of Seattle
                                                                 Seattle Fire Department (SFD)
                                                    _Metropolitan Medical Strike Team (MMST )




(3) Operational Checklist

   Law Enforcement Liaison of the MMST will assist in the following areas:

       (a) Prior to activation:

           Assures personal ‗‗GO‘‘ kit is ready and available for deployment


       (b) Upon activation:

           Receives notification of assignment and Team mobilization location

           Brings Personal ―GO‖ kit

           Monitors disaster-related information from local sources

           Advise their employing agency of the MMST activation requiring their presence.

           Reports to mobilization location

           The Law Enforcement Liaison will coordinate with law enforcement agencies of
           the affected jurisdiction to expedite transit to the incident scene

           Coordinate MMST Operations with Local Police Special Operations Units,
           (SWAT, Bomb Unit, etc.)

       (c) Arrival at incident site:

           Arrivals at incident site should expect chaotic conditions due to the nature of an
           NBC incident. The emphasis of the Law Enforcement Liaison during this phase
           of operations is as follows:

           Advises TFL of arrival

           Affixes appropriate functional identifier

           Establishes communications links with intelligence sources, on and off site

           Receives briefing from TFL




11/05/10                                                                                   3-61
                                                                                  City of Seattle
                                                                 Seattle Fire Department (SFD)
                                                    _Metropolitan Medical Strike Team (MMST )

           If a base of MMST Operations is established, the Law Enforcement Liaison will
           coordinate and assist with the primary law enforcement agency in addressing
           security and staging concerns for MMST members and assets

           Advise the TFL to reinforce to members that no independent law enforcement
           action can be taken without the proper coordination with the primary law
           enforcement agency


      (d) On-site operations:

           The Law Enforcement Liaison, in coordination with the primary law enforcement
           agency, performs the following functions:

           Ensuring personal physical readiness through proper nutrition, water intake, rest,
           and stress control techniques

           Facilitate the gathering and dissemination of intelligence information to the Plans
           Group Supervisor with the assistance of the Intelligence Information Specialist,
           as appropriate

           Coordinating the acquisition of any access pass/badge required by the affected
           jurisdiction and the delivery of such items to MMST members

           Coordinate the establishment of a protective perimeter for the MMST BOO

           Coordinate the establishment of a protective perimeter for MMST vehicles and
           equipment to ensure that only MMST members gain access to such equipment

           Coordinating with the law enforcement agency of the affected agency to resolve
           any problems associated with the arrival and/or departure of MMST assets or
           such other situations as may arise

           Offering assistance regarding crowd management at the incident scene to the
           agency of the affected jurisdiction charged with that responsibility

           Offering assistance regarding victim/patient tracking to the agency of the affected
           jurisdiction charged with that responsibility

           Offering assistance regarding security and evidence processing and custody to the
           agency of the affected jurisdiction charged with that responsibility

           Assist with the medical screening for Security Personnel

           Assist in the handling of media inquiries regarding law enforcement issues



11/05/10                                                                                   3-62
                                                                                   City of Seattle
                                                                  Seattle Fire Department (SFD)
                                                     _Metropolitan Medical Strike Team (MMST )



            Taking all protective measures consistent with the threat posed by the NBC
            incident including wearing protective clothing

            Participates in the decontamination process should the Law Enforcement Liaison
            becomes contaminated

            Brief the Law Enforcement Intelligence Information Specialist on current law
            enforcement issues and plans

            Briefing shift replacement fully on all ongoing operations when being relieved at
            work cycle rotations


      (e) Reassignment/demobilization:

            Reassignment may occur due to multiple NBC incidents within the MMST
            sponsoring jurisdiction and would be done in coordination with the TFL.

            Demobilization activities will occur when the TFL has determined that the IC of
            the affected jurisdiction no longer requires the resources and assets of the MMST.
            Law Enforcement Liaison will be responsible for the following:

               -   Coordinate with the TFL regarding the most efficient departure route
                   from the incident scene to the original mobilization area

               -   Maintaining inventory of equipment assigned to the Law Enforcement
                   Liaison to ensure the accountability of all such equipment

               -   The transfer of notes and information to the appropriate agency should
                   such items have evidentiary value

               -   Law Enforcement Liaison will assist the TFL in ensuring that all MMST
                   personnel who arrived for the deployment are accounted for prior to the
                   MMST leaving the incident scene


      (f)       Post-incident:

            Post-incident activities occur upon return of the MMST to the mobilization area.
            Law Enforcement Liaison responsibilities are as follows:

            Report any ill or unusual feelings or sicknesses that may be attributable to
            exposure at the incident




11/05/10                                                                                    3-63
                                                                                   City of Seattle
                                                                  Seattle Fire Department (SFD)
                                                     _Metropolitan Medical Strike Team (MMST )

           Transfer all equipment assigned to the Law Enforcement Liaison to the MMST
           Logistics Section

           Attend any incident debriefings and any current incident stress management
           sessions that are scheduled for the MMST

           Submits reports to Plans Section for inclusion in the After-Action Report

           Make contact with Law Enforcement Agencies to inform them of the termination
           of their participation in MMST activation and follow the guidance as required by
           their agency

           Restore ‗‗GO‘‘ kit to deployment status

           Law Enforcement Liaison will make contact with their employing agency to
           inform them of the termination of their participation in MMST activation and
           follow the time and attendance reporting requirements of their home jurisdiction

C) Safety Officer

   (1) Introduction

             The Safety Officer is responsible for monitoring and assessing safety
      hazards or unsafe situations and developing measures for ensuring pe rsonnel
      safety. It is the Safety Officer's role to ensure that appropriate safety
      procedures have been identified and are being followe d. MMST personnel
      conducting MMST activities are exposed to many risks and hazards when
      carrying out assignments. If safety is compromised by anyone at any time,
      the consequences could be serious. The Safety Officer reports directly to the
      Task Force Leader (TFL).

   (2) The Safety Officer performs the following duties:

              Is responsible for assuring personnel are following safety procedures

              Keeps the TFL informed of operational problems and potential hazards

              Focuses on the identification of unsafe conditions and practices and
               ensures that solutions are developed to correct the identified problems

              Has the authority to bypass the chain of command when it is necessary to
               immediately correct unsafe acts, such as removing all personnel from
               areas of imminent danger




11/05/10                                                                                    3-64
                                                                                   City of Seattle
                                                                  Seattle Fire Department (SFD)
                                                     _Metropolitan Medical Strike Team (MMST )

              Has the authority to stop all operations when, in his/her judgment, an
               unsafe condition or practice exists that could lead to personal injury or
               death of any personnel

              Has the responsibility to implement an appropriate site safety plan for
               MMST operations in coordination with the local jurisdiction's Incident
               Command System (ICS)

              If a site safety plan does not exist, then he/she will ensure that one is
               established to protect all MMST members

              Assures that the Passport System has been implemented

              Assures, in coordination with the Team Medical Section Chief, that
               medical surveillance is initiated on team members who are making entries
               and/or are suiting up

          Submits safety-related documentation

   (3) Ope rational Checklist

               (a) Prior to activation:

           Reviews safety guidelines and is cognizant of changes in the areas of safety
           practices

           Forwards safety information to all members as received from various sources

           Ensures personal ''GO'' kit is available and ready for deployment


      (b) Upon activation:

           Receives notification of assignment and team mobilization location

           Reports to mobilization location

           Monitors disaster-related information from local sources


      (c) At mobilization site:

           Advises TFL of arrival

           Receives TFL briefing


11/05/10                                                                                    3-65
                                                                                   City of Seattle
                                                                  Seattle Fire Department (SFD)
                                                     _Metropolitan Medical Strike Team (MMST )



           Monitors loading of the equipment cache

           Ensures that MMST members arrive at the mobilization site with ''GO'' kit

           Assesses, with the Team Medical Section Chief, the current mental/physical
           fitness for duty of MMST members

           Affixes appropriate functional identifier

           Brings personal ''GO'' kit


      (d) In transit:

           Monitors reports from incident site to determine safety issues to be addressed
           upon arrival

           Ensures unsafe practices do not occur during transport to the site

           Reviews Safety Officer responsibilities

           Emphasizes safety concerns during transport reiterating that all personnel are
           responsible for their own safety and actions


      (e) On-site ope rations:

           Receives briefing from TFL

           Ensures that equipment and personnel stage at an appropriate distance and
           direction from incident

           Locates Incident Command Post (ICP) and establishes liaison with local
           Safety Officer

           Informs MMST members of hot, warm, cold zone, rehab and ICP locations

           Reviews site plan and passes information along to TFL and team members,
           noting unusual terrain features and operational hazards

           Reviews site plan for preplanned escape routes and ensures that all members
           are aware of them




11/05/10                                                                                    3-66
                                                                                 City of Seattle
                                                                Seattle Fire Department (SFD)
                                                   _Metropolitan Medical Strike Team (MMST )

           Assures that all personnel know the emergency alerting and evacuation system
           and where to report if the system is activated

           Assures that all entry team personnel are working in teams

           Assures that all personnel have the appropriate PPE for the type incident
           and/or agent

           Ensures that all used equipment and supplies are properly decontaminated
           and/or properly disposed

           Coordinates with the Team Medical Section Chief to ensure that a safe rehab
           area with food and drink is established for expended Team members

           Establishes perimeter observation points to constantly monitor
           activities/operations for changing conditions and unsafe operations

           Ensures personal physical readiness through proper nutrition, water intake,
           rest, and stress control techniques

           Monitors personnel for signs of fatigue, psychological stress, and injury

           Assures that atmospheric/meteorological conditions are constantly monitored

           During night operations, assures that adequate lighting is available and is used
           effectively

           Coordinates air space closure over incident site with the TFL

           Assures that entry teams can exit the hot and warm zones within the
           timeframe of the suit and respiratory protection they are using

           Assures team member compliance with MMST standard operating procedures
           (SOPs) for their assignment

           Identifies signs of medical or psychological injury to any team personnel and
           initiates preliminary corrective action

           Reviews personnel accountability check every 30 minutes or more often as
           necessary

           Briefs shift replacement fully on all ongoing operations when being relieved
           at work cycle rotations




11/05/10                                                                                  3-67
                                                                                  City of Seattle
                                                                 Seattle Fire Department (SFD)
                                                    _Metropolitan Medical Strike Team (MMST )

      (f) Demobilization:

           Monitors reloading of MMST cache to assure safe practices are being
           followed

           Investigates accidents, collects data, and files the appropriate report on any
           accidents that occurred during the incident

           Assures completion of accident/injury forms

           Returns issued items to Logistics Section

           Prepares a MMST review (critique) of safety issues

           Ensures that a Critical Incident and Stress Management (CISM)
           defusing/debriefing is conducted at an appropriate time and place

           Ensures that safety findings and lessons are incorporated into future training
           sessions, field exercises, and operational procedures

           Assures that all personal safety equipment is restocked to original levels


      (g) Post-incident:

           Reports any ill or unusual feelings or sicknesses that may be attributable to
           exposure at the incident

           Submits safety reports to Plans Section Chief for inclusion in After-Action
           Report

           Participates in MMST mission critique and CISM debriefing

           Restores personal ''GO'' kit to deployment status

           Safety Chief will make contact with their employing agency to inform them of
           the termination of their participation in MMST activation and follow the time and
           attendance reporting requirements of their home jurisdiction.




11/05/10                                                                                   3-68
                                                                                    City of Seattle
                                                                   Seattle Fire Department (SFD)
                                                      _Metropolitan Medical Strike Team (MMST )

D) Medical Director

   (1) Introduction

      The Medical Director is a physician responsible for the primary oversight of all
      medical aspects of MMST operations.


   (2) The Medical Director performs the following duties:

              Assures the general health and medical care for all MMST personnel and
               incident victims

              Serves as the medical advisor to the TFL

              Develops and implements the medical action plan in conjunction with Team
               Medical Section Chief and the Safety Officer

              Supervises medical care delivery to MMST personnel and incident victims

              Assures effective liaison with local EMS agency and medical facilities

              Performs additional tasks and duties as assigned during a mission


   (3) Operational Checklist

      (a) Prior to activation:

           Ensures ‗‗GO‘‘ kit is ready and available for deployment

           Provides advice and direction on medical aspect of MMST planning and training


      (b) Upon activation:

           Receives notification and instructions for arrival at the mobilization site

           Monitors disaster-related information from local sources

           Reports to the assigned mobilization point, as indicated




11/05/10                                                                                     3-69
                                                                                     City of Seattle
                                                                    Seattle Fire Department (SFD)
                                                       _Metropolitan Medical Strike Team (MMST )



      (c) At mobilization site:

           Affixes appropriate functional identifier

           Brings personal ‗‗GO‘‘ kit

           Notifies the TFL of arrival

           Signs NDMS (National Medical Disaster Plan) liability coverage form, if
           appropriate

           Assembles for MMST briefing from the TFL and appropriate local officials

           Coordinates the security and accountability of controlled drugs with the Team
           Medical Section Chief and Logistics Section Chief

           Assures personnel have designated antidote kit


      (d) In transit:

           Reviews the latest available disaster-related information

           Reviews information pertinent to position description

           Develops preliminary medical support plan with Team Medical Section Chief,
           Safety Officer and Plans Section Chief

           Ensures personal physical readiness through proper nutrition, water intake, rest,
           and stress control techniques


      (e) On-site operations:
           Supervises medical care to injured civilians in accordance with the appropriate
           MMST Medical Protocol

           Supervises medical care to injured local responders and MMST members in
           accordance with the appropriate MMST Medical Protocol

           Makes final decisions regarding patient treatment when questions arise on scene

           Briefs shift replacement fully on all ongoing operations when being relieved at
           work cycle rotations



11/05/10                                                                                      3-70
                                                                                 City of Seattle
                                                                Seattle Fire Department (SFD)
                                                   _Metropolitan Medical Strike Team (MMST )



      (f) Demobilization:

           Assists TFL in determining incident management termination for MMST

           Ensures collection and return of issued equipment and supplies to Logistics
           Section

           Ensures that hospitals and Poison Control Center is notified of incident
           termination


      (g) Post-incident:

           Reports any ill or unusual feelings or sicknesses that may be attributable to
           exposure at the incident

           Assures all personnel attend mission critique and CISM activity

           Submits applicable reports to Plans Section Chief for inclusion in the After-
           Action Report

           Ensures medical equipment is operational for next mission

           Ensures personal ‗‗GO‘‘ kit is ready for next deployment

           The Medical Director will make contact with their employing agency to inform
           them of the termination of their participation in MMST activation and follow the
           time and attendance reporting requirements of their home jurisdiction.




11/05/10                                                                                  3-71
                                                                                   City of Seattle
                                                                  Seattle Fire Department (SFD)
                                                     _Metropolitan Medical Strike Team (MMST )

E) Hos pital Liaison

   (1) Introduction

              The Hospital Liaison will be a:

               -   Emergency Physician, or
               -   Emergency Department Physician Assistant or Nurse Practitioner, or
               -   Critical Care or Emergency Department Registered Nurse, or
               -   Firefighter/Paramedic


   (2) The Hospital Liaison will perform the following duties:

              Serve as liaison between the MMST and local medical fac ilities receiving
               patients

              Assist the host jurisdiction with communicating vital information to each
               receiving hospital or the command hospital

              Work with the Medical Director and Team Medical Section Chief to provide
               the medical community the needed patient care information for the agent(s)
               involved

              Assist in implementing a system of patient tracking in concert with the on-
               scene EMS personnel and facilities receiving patients

              Identify the antidote needs of each facility and assist them in obtaining the
               needed items from the Team cache, regional cache, government agencies, or
               vendors

              When requested, serve as clinical consultants to the medical staff at each
               medical facility providing advice on patient care, personnel safety, or facility
               protection


   (3) Operational Checklist

       (a) Prior to activation:

           Ensure personal ‗‗GO‘‘ kit is ready and available for deployment




11/05/10                                                                                    3-72
                                                                                     City of Seattle
                                                                    Seattle Fire Department (SFD)
                                                       _Metropolitan Medical Strike Team (MMST )

      (b) Upon activation:

           Receive notification of assignment and team mobilization location

           Monitor disaster-related information from local sources

           Advises their employing agency of the MMST activation requiring their presence

           Reports to mobilization location


      (c) At mobilization site:

           Affixes appropriate functional identifier

           Brings personal ―GO‖ kit

           Advise TFL of arrival and receive briefing

           Assist with transfer and loading of MMST equipment as necessary


      (d) In transit:

           En route to the scene, the Hospital Liaison will attempt to gather reconnaissance
           information from the on-site EMS officer, including:

             - Agent(s) involved
             - Number of injuries involved
             - Treatment being done in the field
             - Hospitals receiving patients

           Determine with the TFL whether to go to incident site or Poison Control Center

           Determine how to disseminate preliminary information to the medical fac ilities

           Determine what information will be given to the medical facilities

           Establish how the patient tracking system should be implemented

           Review the latest disaster information

           Review information pertinent to position description, operations, checklis t,
           operational procedures, and safety procedures




11/05/10                                                                                      3-73
                                                                                    City of Seattle
                                                                   Seattle Fire Department (SFD)
                                                      _Metropolitan Medical Strike Team (MMST )

           Take advantage of travel time for rest prior to arrival

      (e) On-site operations:

           Ensure personal physical readiness through proper nutrition, water intake, rest,
           and stress control techniques

           The Hospital Liaison will address issues of:

               -   Hospital communications
               -   Patient tracking
               -   Hospital supply

           Communications with each receiving facility shall be done by all available means
           as soon as possible to:

               -   Ensure that they have been given preliminary information
               -   Reconfirm facsimile, modem, and phone numbers that can be used for
                   communication
               -   Identify Hospital Liaison for future communication
               -   Identify any preliminary antidote need

           All communications with a medical facility should be recorded on a
           communication log.

           The Hospital Liaison shall, via direct communication and listening to the radio,
           keep abreast of changing conditions and update their personnel when indicated.

           A patient tracker will be designated. He/she will keep records of all patients sent
           to a medical facility by maintaining contact with the appropriate Command Post
           staff and periodic questioning of each receiving facility. Reasonable attempts to
           reconcile differences in patient counts are to be undertaken. Patient tracking is to
           be done using the MMST Patient Census Log, or equivalent.

           Receiving treatment facilities may request on-site assistance from the MMST.
           That request should be addressed to the Command Post. The request will be met
           if resources permit and the overall mission objectives of the MMST will not be
           compromised.




11/05/10                                                                                     3-74
                                                                                 City of Seattle
                                                                Seattle Fire Department (SFD)
                                                   _Metropolitan Medical Strike Team (MMST )

      (f) Arrival at secondary site/treatment facility:

           Team personnel will, when requested, advise treatment facility personnel in the
           clinical management of patients arriving at that location. This assistance could
           include:

              -   Making treatment recommendations
              -   Providing advice on decontamination procedures to be utilized
              -   Suggesting PPE and hospital protection measures
              -   Working to acquire vendor assistance for needed equipment and supplies
              -   Working with the TFL and Logistics Section to acquire needed inventory
                  from the medical cache
              -   Normally, at this stage of the incident MMST personnel will not
                  physically be involved in providing direct patient care or performing
                  decontamination. However, the Hospital Liaison or his on-site designee
                  will have the prerogative of modifying this practice if patient care
                  interests would be better served by more direct interaction by team
                  personnel.


           Once at the assigned secondary duty location, the Hospital Liaison will meet with
           the individual responsible for directing the activities in that area to:

              -   Give a briefing on team capability and personnel identification
              -   Report updated incident medical information that is known
              -   Ascertain how patients at that treatment facility are currently being
                  managed
              -   Obtain telephone and fax numbers that can be used by the Command Post
                  for communication

           The Hospital Liaison will work with a liaison from the facility to determine how
           MMST personnel can best be used.

           Once at the site and after an operational plan has been established, the Hospital
           Liaison or his designee will advise the TFL of the team‘s status by appropriate
           communication means.

              -   The Hospital Liaison will, via face-to-face communication and listening
                  to the radio, keep abreast of changing conditions and update his personnel
                  when appropriate.

              -   The Hospital Liaison will work with Command Post personnel (i.e.,
                  logistician) to resolve procedure and/or supply issues involving receiving
                  facilities.




11/05/10                                                                                  3-75
                                                                                  City of Seattle
                                                                 Seattle Fire Department (SFD)
                                                    _Metropolitan Medical Strike Team (MMST )




              -   The Hospital Liaison, Medical Director, Team Medical Section Chief,
                  and TFL will regularly discuss optimum use of team resources to
                  effectively meet the patient care needs at the incident site and the
                  treatment facilities. These discussions will include:

              (1) Redeployment of team personnel to treatment facilities

              (2) Distribution of MMST pharmacy equipment and/or supplies to treatment
                  facilities

              (3) Expedient means to acquire and distribute other stockpiled pharmacy
                  items

              -   Steps shall be taken to continuously inform each treatment facility of
                  pertinent new information that will affect their clinical and personnel
                  safety practices.

              -   Medical care items distributed to treatment facilities are to be recorded on
                  the MMST Inventory Log.

           Briefs shift replacement fully on all ongoing operations when being relieved at
           work cycle rotations


      (g) Demobilization:

           The Hospital Liaison, in consultation with the TFL will determine when his/her
           operation should be terminated.

           No team personnel will leave their duty location without ensuring that the
           treatment facility has been consulted on the advisability of this decision.

           Assure that hospitals and Poison Control Center are notified of incident
           termination.

           Assigned equipment and supplies will be inventoried, returned to the cache, and
           prepared for movement.

           Team personnel will report to the designated demobilization site in a timely
           manner bringing with them MMST equipment and supplies that are no longer
           needed at the treatment facility. If select items are to remain at the treatment
           facility, equipment inventory numbers are to be noted by the Hospital Liaison and




11/05/10                                                                                   3-76
                                                                                   City of Seattle
                                                                  Seattle Fire Department (SFD)
                                                     _Metropolitan Medical Strike Team (MMST )

           reported to the Logistics Section who will later make arrangements to recover the
           items.

           All team personnel will assemble for team briefing or mission status and
           reassignment/demobilization determinations.

           All items issued to Hospital Liaison from the cache are to be returned to the
           Logistics Section.

           Logistics Section will be notified of the loss or potential maintenance
           requirements of any tools and equipment.

           Team personnel will assist with the loading of the cache for the trip home.


      (h) Post-incident:

           Reports any ill or unusual feelings or sicknesses that may be attributable to
           exposure at the incident.

           Reports will be submitted to Plans Section Chief for inclusion in the After-Action
           Report.

           Medical surveillance reports are to be completed and returned to the Safety
           Officer.

           Injury reports will be completed where indicated.

           Physical examinations will be conducted where indicated by MMST Medical
           Director and/or designated clinical specialists.

           All team personnel will participate in both the mission critique and CISM session
           when they are held.

           Restores ―GO‖ kit to deployment status.

           Hospital Liaison will make contact with their employing agency to inform them
           of the termination of their participation in MMST activation and follow the time
           and attendance reporting requirements of their home jurisdiction.




11/05/10                                                                                    3-77
                                                                                                                                                       City of Seattle
                                                                                                                                      Seattle Fire Department (SFD)
                                                                                                                         _Metropolitan Medical Strike Team (MMST )


                                                      Seattle Fire Department

                              METRO MEDICAL STRIKE TEAM      (Proposed 62 Person Team)




                                                                     TFL

                                                  Law Enforcement                    Safety
                                 Security             Liaison                        Officer


                                                      Medical                       Hospital
                                                      Director                      Liaison



                  OPERATIONS                        PLANS                                      LOGISTICS                     TEAM-MEDICAL
                   SECTION                         SECTION                                      SECTION                        SECTION
                     CHIEF                          CHIEF                                        CHIEF                          CHIEF


     Field-Medical (FM)     Field-HazMat (FH)        Plans                 Communications                   Logistics              TM - Unit 1
           Group                  Group             Group                      Group                         Group                1 Unit Leader
         Supervisor             Supervisor         Supervisor                Supervisor                    Supervisor              1 Specialist

                                                                                                                                   TM - Unit 2
             FM - Unit 1           FH - Unit 1         Intelligence                 Comm Unit                 Log. Unit 1         1 Unit Leader
           1 Unit Leader         1 Unit Leader       Info - Specialist              1 Specialist             1 Unit Leader         1 Specialist
            5 Specialists         5 Specialists    (Law Enforcement)                                          1 Specialist

             FM - Unit 2           FH - Unit 2          HazMat                                                Log. Unit 2
           1 Unit Leader         1 Unit Leader      Info - Specialist                                        1 Unit Leader
            5 Specialists         5 Specialists        (Chemist)                                              1 Specialist

                                   FH - Unit 3          Medical
                                 1 Unit Leader      Info - Specialist
                                  5 Specialists      (Toxicologist)

                                   FH - Unit 4
                                 1 Unit Leader
                                  5 Specialists




11/05/10                                                                                                    3-78
                                                                                  City of Seattle
                                                                 Seattle Fire Department (SFD)
                                                    _Metropolitan Medical Strike Team (MMST )



II. FIELD OPERATIONS SECTION

   A) Ope rations Section Chief

   (1) Introduction

      The Operations Section Chief is responsible for the management and supervision
      of all Team activities directly related to the Operations Section. The Operations
      Section Chief reports directly to the TFL. In the event of the absence or
      incapacitation of the Task Force Leader, the Operations Section Chief would
      assume the Task Force Leader's positional responsibilities.


   (2) The Operations Section Chief performs the following duties:

              Assists the TFL in the coordination and supervision of all team activities

              Is directly responsible for managing field operations

              Possesses flexibility to be available to mobilize on short notice

              Possesses knowledge of the Federal Response Plan (FRP) and how the
               mission of the MMST fits into that plan

              Develops the MMST portion of the field operations plan of the IAP

              Briefs and assigns operations section personnel in accordance with the
               IAP

              Possesses a comprehensive knowledge of MMST functions, operations,
               tactics, strategy, and safety considerations

              Possesses strong interpersonal relations skills

              Possesses good interagency coordination skills and the ability to work well
               with various technical components and other organizations

              Possesses ability to communicate effectively orally and in writing

              Possesses knowledge of the practical application of available technology
               used to support MMST missions and objectives

              Possesses ability to be flexible, to improvise, share information, resolve
               conflicts, and solve problems


11/05/10                                                                                   3-79
                                                                                 City of Seattle
                                                                Seattle Fire Department (SFD)
                                                   _Metropolitan Medical Strike Team (MMST )

              Assures adherence to all safety procedures

              Assists the TFL by planning the future of the event (several hours)

              Assists in overseeing the overall safety of the operation in coordination
               with the Safety Officer

              Continues operational responsibility for a portion of the MMST if the
               team is divided for response to multiple sites


   (3) Operational Checklist

      (a) Prior to activation:

      Works with the TFL to ensure team operational readiness

      Assists the TFL in crisis management training activities

      Assists the TFL in developing preliminary response plans

      Ensures personal ''GO'' kit is available and complete


      (b) Upon activation:

           Receives notification of assignment and details of the event

           Disseminates appropriate information to the appropriate personnel, as
           assigned

           Monitors disaster-related information from local sources


      (c) At mobilization site:

           Determines all assigned MMST Operations Section members are present

           Assures the equipment/cache is brought to the designated site

           Consults with the TFL on mission objectives and assignments

           Affixes appropriate functional identifier

           Brings personal ''GO'' kit


11/05/10                                                                                  3-80
                                                                                City of Seattle
                                                               Seattle Fire Department (SFD)
                                                  _Metropolitan Medical Strike Team (MMST )



           Assigns Medical Specialist to Field Medical or Team Medical Group


      (d) In transit:

           Reviews latest information as it becomes available

           Reviews information pertinent to their position description and ensures
           personnel assigned to Field Operations Section reviews information pertinent
           to their position description

           Discusses and coordinates with appropriate MMST Command staff to assure
           anticipated logistical requirements (personal protective equipment (PPE),
           decon requirements, communications protocols, and medical care issues) are
           met


      (e) On-site ope rations:

           Assists the Safety Officer in establishing a site safety plan; implementing a
           passport accountability system; and establishing hot, warm, and cold zones if
           not already established

           Ensures personal physical readiness through proper nutrition, water intake,
           rest, and stress control techniques

           Performs other duties and assignments as determined by the TFL

           Briefs shift replacement fully on all ongoing operations when being relieved
           at work cycle rotations


      (f) Demobilization:

           Assembles for and may conduct team briefing on mission status and
           reassignment/demobilization determinations

           Assures that a preliminary inventory of assigned equipment is performed to
           ensure all is accounted for and returned intact to cache

           Returns issued items to Logistics Section

           Assigns members to assist in the breakdown and repacking of equipment,
           supplies, and materials to return to the equipment cache



11/05/10                                                                                 3-81
                                                                                 City of Seattle
                                                                Seattle Fire Department (SFD)
                                                   _Metropolitan Medical Strike Team (MMST )

      (g) Post-incident:

           Reports any ill or unusual feelings or sicknesses that may be attributable to
           exposure at the incident

           Assists with critical review of team performance

           Submits reports to Plans Section Chief for inclusion in the After-Action
           Report

           Assures that the MMST cache is returned to deployment status

           Restores personal ''GO'' kit to deployment status

           Operations Section Chief will make contact with their employing agency to
           inform them of the termination of their participation in MMST activation and
           follow the time and attendance reporting requirements of their home
           jurisdiction.

B) Field Medical Group Supervisor

   (1) Introduction

   The Field Medical Group Supervisor is responsible for managing and supervising the
          Field Medical Specialists. The Field Medical Group Supervisor reports
          directly to the Operations Section Chief.


   (2) The Field Medical Group Supervisor pe rforms the following duties:

              Responsible for the development and implementation of the Field Medical
               Section plan

              Assist the Operations Section Chief in designating medical specialists to
               serve on Field Medical or Team Medical Groups

              Supervises the Field Medical Specialists

              Ensures that local response personnel are assisted with intelligence
               gathering, product identification, victim rescue, decontamination, patient
               care, patient tracking, and scene security

              Assures that proper medical care is rendered to MMST personnel and
               disaster victims



11/05/10                                                                                  3-82
                                                                                   City of Seattle
                                                                  Seattle Fire Department (SFD)
                                                     _Metropolitan Medical Strike Team (MMST )

               Develops a casualty evacuation plan

               Assures that all equipment issued to the Field Medical Operations Section
                is accounted for and used properly

               Assures that all on-site activities are done in a safe and coordinated
                fashion

               Receives briefings and situation reports and ensures that all section
                personnel are kept informed of status changes

               Provides situation reports, maintains Field Medical Operations Section
                records and reports, and prepares the Field Medical Operations Section
                portion of the After-Action Report

               Performs additional tasks and duties as assigned during the mission


   (3) Ope rational Checklist

      (a) Prior to activation:

      Ensures ''GO'' kit is available and ready for deployment


      (b)       Upon activation:

      Receives notification and location of mobilization site

      Monitors disaster-related information from local sources


      (c)       At mobilization site:

      Affixes appropriate functional identifier

      Brings personal ''GO'' kit

      Advises the Operations Section Chief of arrival and receives briefing

      Ensures all assigned field medical personnel have arrived

      Assists with movement/loading of equipment cache




11/05/10                                                                                    3-83
                                                                                    City of Seattle
                                                                   Seattle Fire Department (SFD)
                                                      _Metropolitan Medical Strike Team (MMST )

            Ensures all section personnel have signed U.S. Public Health Service National
            Disaster Medical System liability coverage form, if appropriate

            Assures antidote kits are issued to assigned personnel, if indicated

            Coordinates with logistics personnel the off- loading and security of personal
            gear and MMST medical equipment

            Assembles for general mission briefing from the TFL and other appropriate
            local officials

            As necessary, assists in the departure to the incident site or assignment
            destination

            Receives initial briefing of tactical assignments from the TFL including:
               - Incident Situation Report
               - Incident site mission objectives
               - Tactical assignments
               - Communications plan, including frequencies, and radio designations
               - Emergency signaling/evacuation procedures
               - Patient decontamination procedures
               - Medical treatment procedures
               - Process for procuring additional supplies and equipment
               - Proper patient documentation and on-site record-keeping procedures


      (d)       In transit:

            Reviews the latest disaster information

            Reviews information pertinent to position, operations checklist, operational
            procedures and safety procedures

            Initiates pre-entry monitoring of personnel if practical

            Establishes communication with local EMS Control Officer to receive
            updated information

            Takes advantage of travel time for rest prior to arrival

            Works with Information Specialists to begin product ID procedure




11/05/10                                                                                     3-84
                                                                                 City of Seattle
                                                                Seattle Fire Department (SFD)
                                                   _Metropolitan Medical Strike Team (MMST )

      (e)       On-site operations:

            Ensures section personnel are assigned to Logistics to off- load MMST Cache

            Assures Field Medical Operations Section is established

            Receives TFL updated briefing

            Assures patient decon is established per Appendix E

            Assures team member decon is established per Appendix F

            Assures emergency decon is established per Appendix G

            Ensures rehab area is established in concurrence with Team Medical Section
            Chief

            Assures emergency warning signals are understood by personnel

            Assures communication system with various MMST sections is established

            Assures interaction with local HazMat Team to address incident mitigatio n
            issues

            Assures interaction with local EMS to address patient care issues

            Assures safe practices are being followed by all section personnel

            Assures personnel accountability check is done at a minimum of every 30
            minutes and more often if warranted

            Establishes work/rest rotation schedule for the Field Medical Group

            Assures needed equipment and supplies are obtained from Logistics Section

            Evaluates ongoing team operations for effectiveness and modifies where
            necessary

            Assures health and welfare needs of team personnel are met

            Resolves any coordination, communication, or personnel problems with
            section leaders

            Ensures personal physical readiness through proper nutrition, water intake,
            rest, and stress control techniques



11/05/10                                                                                  3-85
                                                                                  City of Seattle
                                                                 Seattle Fire Department (SFD)
                                                    _Metropolitan Medical Strike Team (MMST )



            Ensures injured MMST personnel are promptly and properly cared for

            Keeps Operations Section Chief and Field HazMat Group Supervisor abreast
            of current information and incident management strategies

            Makes periodic progress reports to Operations Section Chief of
            accomplishments, conflicts, or operational needs

            Confers with Team Medical Section Chief in resolving medical care-related
            problems

            Assures completion of patient evaluation/call forms and Control Drug
            Accountability forms

            Participates in MMST strategy sessions with TFL

            Updates shift replacement fully in ongoing operations when relieved at work
            cycle rotations


      (f)       Demobilization:

            Reviews the status of the current team assignment and advises the Operations
            Section Chief on any necessary operational changes or adjustments

            Briefs field medical personnel on mission status and
            reassignment/demobilization directions

            Assures all assigned tools and equipment are inventoried, returned to cache,
            and prepared for movement

            Assures Logistics Section is advised of broken or missing equipment and tools

            Assures Base of Operations (BOO) is broken down and policed


      (g)       Post-incident:

            Reports any ill or unusual feelings or sicknesses that may be attributable to
            exposure at the incident

            Coordinates participation of field medical personnel in MMST mission
            critique and CISM




11/05/10                                                                                   3-86
                                                                                    City of Seattle
                                                                   Seattle Fire Department (SFD)
                                                      _Metropolitan Medical Strike Team (MMST )

           Receives reports from Field Medical Specialists and submits the appropriate
           reports to the Plans Section Chief for inclusion in the After-Action Report

           Restores ''GO'' kit to deployment status

           Assures Field Operations Section equipment cache is ready for next
           deployment

           Section member will make contact with their employing agency to inform them
           of the termination of their participation in MMST activation and follow the time
           and attendance reporting requirements of their home jurisdiction




11/05/10                                                                                     3-87
                                                                                     City of Seattle
                                                                    Seattle Fire Department (SFD)
                                                       _Metropolitan Medical Strike Team (MMST )

C) Field Medical Specialist

   (1) Introduction

       The Medical Specialist is a Firefighter/Paramedic and will be responsible for
       performing medical care at an incident. All Medical Specialists report to the
       Operations Section Chief for assignment to Field Medical or Team Medical Group.


   (2) The Medical Specialist is responsible for the following duties:

              The general health and medical care for all MMST personnel and incident
               victims

              The implementation of the medical action plan

              Providing medical care in accordance with MMST treatment protocols

              Additional task and duties as assigned

              Will be prepared to accept the assignment of unit leader


   (3) Operational Checklist

       (a) Prior to activation:

           Ensures personal ―GO‖ kit is available and ready for deployment


       (b) Upon activation:

           Receives notification and instructions for arrival at the mobilization site

           Monitors disaster-related information from local sources

           Reports to the assigned mobilization point


       (c) At mobilization site:

           Affixes appropriate functional identifier

           Brings personal ―GO‖ kit



11/05/10                                                                                      3-88
                                                                                    City of Seattle
                                                                   Seattle Fire Department (SFD)
                                                      _Metropolitan Medical Strike Team (MMST )

           Notifies the Operations Section Chief of arrival and receives assignment

           Assists with the transfer and loading of MMST medical equipment, as necessary

           Assembles for MMST briefing from the TFL

           Coordinates the security and accountability of controlled drugs with the Logistics
           Section Chief and Team Medical Section Chief


      (d) In transit:

           Reviews information pertinent to their position description, operations, checklist,
           operational procedures and safety procedures

           Reviews latest disaster-related information available

           Take advantage of available time to rest


      (e) On-site operations:

           Performs pre- and post-entry medical surveillance on MMST personnel donning
           PPE

           Assists personnel donning PPE

           Ensures personal physical readiness through proper nutrition, water intake, rest,
           and stress control techniques

           The treatment priorities for medical personnel (including field members) are:

              First, MMST personnel
              Second, local response personnel who become ill or injured
              Third, victims directly encountered by the MMST
              Fourth, other injured/affected persons as practical


           Assists with patient decontamination when directed by the Field Medical Group
           Supervisor

           Completes appropriate medical records

           Accompanies injured MMST personnel to the hospital when directed by the TFL



11/05/10                                                                                     3-89
                                                                                  City of Seattle
                                                                 Seattle Fire Department (SFD)
                                                    _Metropolitan Medical Strike Team (MMST )

           Thoroughly briefs shift replacement on all ongoing operations when being
           relieved at work cycle rotations


      (f) Demobilization:

           Advises Group Supervisor when assignments are completed

           Assists with the breakdown of their assigned section

           Assures collection and return of equipment and supplies to Logistics Section


      (g) Post-incident:

           Reports any ill or unusual feelings or sicknesses that may be attributable to
           exposure at the incident

           Participates in MMST mission critique and CISM debriefing

           Completes reports and forwards to the Field Medical Group Supervisor for
           inclusion in the After-Action Report

           Assists with assuring cache is ready for next deployment

           Restores ―GO‖ kit to deployment status

           Section members will make contact with their employing agency to inform them
           of the termination of their participation in MMST activation and follow the time
           and attendance reporting requirements of their home jurisdiction.




11/05/10                                                                                   3-90
                                                                                  City of Seattle
                                                                 Seattle Fire Department (SFD)
                                                    _Metropolitan Medical Strike Team (MMST )

D) Field HazMat Group Supervisor
   (1) Introduction

           The Field HazMat Group Supervisor reports directly to the Operations Section
           Chief. The Field HazMat Group Supervisor is responsible for supervision of all
           technical aspects of HazMat management including:

              Recon
              Product sampling
              Victim rescue
              Neutralization
              Diking
              Damming
              Decontamination


   (2) Description of Duties

              Works with the Information Specialists to identify the causative agent(s)

              Assures the ongoing monitoring of environmental conditions during MMST
               operations

              Assures initial and ongoing surveys are completed for determination of the
               presence of chemical, biological, or radioactive agents

              Assures the implementation of defensive mitigation practices when indicated

              Assures that emergency decontamination procedures are in place for MMST
               members

              Assures that information regarding the agent(s) and patient symptomatology
               are passed on to the Medical Director and Team Medical Section Chief

              Assures patients are properly deconned

              Assures personnel wearing PPE are properly deconned upon completion of
               their work rotation

              Assures the documentation of all required information

              Identifies operational issues related to work being done in the hot and warm
               zone and indicates appropriate corrective action



11/05/10                                                                                   3-91
                                                                                     City of Seattle
                                                                    Seattle Fire Department (SFD)
                                                       _Metropolitan Medical Strike Team (MMST )

              Oversees the correct operation of all issued HazMat equipment

              Performs additional tasks or duties as assigned


   (3) Operational Checklist

      (a) Prior to activation:

           Ensures ‗‗GO‘‘ kit is ready and available for deployment


      (b) Upon activation:

           Receives notification of mobilization and reports to designated mobilization point

           Monitors incident-related information from local sources


      (c) At mobilization site:

           Advises Operations Section Chief of arrival and receives briefing

           Determines all assigned Field HazMat Specialists are present

           Assists with movement/loading of HazMat equipment cache

           Affixes appropriate functional identifier

           Brings personal ―GO‖ kit

           Ensures receipt of the appropriate issue of gear pertinent to position

           Receives notification of assignment and instructions from the Operations Section
           Chief

      (d) In transit:

           Reviews the latest incident-related information

           Reviews information pertinent to position description, operational checklist,
           operational procedures, and safety procedures

           Takes advantage of travel time for rest prior to arrival




11/05/10                                                                                      3-92
                                                                                   City of Seattle
                                                                  Seattle Fire Department (SFD)
                                                     _Metropolitan Medical Strike Team (MMST )



      (e) On-site operations:

           Provides assistance to the Logistics Section with the unloading, sorting, and setup
           of the equipment cache and the MMST support facilities when indicated

           Identifies cache supplies and equipment that should receive priority for initial
           movement to the assigned area

           Assembles for a general mission briefing from the TFL and appropriate officials
           from the local jurisdiction

           Assists as necessary in the departure to the incident site or assignment destination

           Assures personnel have designated antidote kit

           Receives and reviews briefing of tactical assignment from the TFL including:

               -   Incident situation report
               -   MMST objectives
               -   Tactical assignments
               -   MMST support layout/requirements (Base of Operations)
               -   Briefing on the communications plan, frequencies, and radio designations
               -   Emergency signaling/evacuation procedures
               -   Medical treatment/evacuation procedures
               -   Process for ordering supplies/equipment


           Prepares to initiate immediate reconnaissance operations

           Assures immediate setup of emergency decon

           Supervises the setup of dress-out area

           Assures proper safety check is performed on each team member dressed in PPE
           before entry into warm or hot zone

           Assures the reconnaissance of affected areas is conducted:

               -   Conducts rapid assessment of the affected area
               -   Identifies the location of areas affected
               -   Identifies potential areas or buildings that require a more detailed
                   assessment or reconnaissance

           Monitors and coordinates reconnaissance procedures with on-site HazMat Team



11/05/10                                                                                    3-93
                                                                                    City of Seattle
                                                                   Seattle Fire Department (SFD)
                                                      _Metropolitan Medical Strike Team (MMST )



           Works with Information Specialists on product identification procedures

           Coordinates with the TFL and the Medical Director for the evaluation of the local
           capabilities to treat contaminated or exposed fire/rescue/law enforcement
           personnel

           Establishes a local site survey for the general area. Sketches the general area and
           notes the following:

               -   Location and status of major fixed facilities and transportation lines (e.g.,
                   nuclear power facilities, hazardous waste sites, refineries, etc.)
               -   Topography
               -   Prevailing short- and long-term weather conditions as monitored by local
                   meteorological devices (i.e., present, 6-hour, 24-hour, and 72-hour
                   forecasts)
               -   Evidence of smoke, flame, vapor cloud, or obvious dead vegetation,
                   animals, or people

           Determines need/benefit of aerial reconnaissance

           Identifies issues that could require the determination of:

               -   Conditional entry or
               -   The cessation of MMST operations

           Conducts a site survey of all involved areas to determine the presence of:

               -   Chemical agents
               -   Flammable atmospheres
               -   Radiation levels
               -   Biological agents or contaminants
               -   Other specific products as indicated

           Takes appropriate corrective action if the following conditions exist:

               -   Any positive flammable gas indicator readings
               -   Oxygen levels below 20% or above 23.5%
               -   Any toxic material readings within 10% of its immediately dangerous to
                   life and health (IDLH) levels
               -   Obvious physical dangers (ex., fires, wreckage, etc.) that exist and pose
                   harm/risk to personnel
               -   Team member becomes ill or injured




11/05/10                                                                                     3-94
                                                                                  City of Seattle
                                                                 Seattle Fire Department (SFD)
                                                    _Metropolitan Medical Strike Team (MMST )

           Works with Information Specialists to verify agent type and presence by
           utilizing the appropriate test equipment and further verifies meter readings with
           a second means of detection and different operator, if possible. All readings will
           be documented according to operator and meter unit numbers and will denote
           the findings, time, and location.

           Documents all events and forwards documentation to the Plans Section. The
           following documents, as a minimum, are required:

              -   Site survey
              -   Site safety plan
              -   Perimeter and entry readings
              -   Product identification form
              -   Decontamination plan

           Monitors ongoing working sites as necessary. Provides technical assistance to
           the appropriate supervisory position

            Works with the Safety Officer to ensure all proper safety practices and
             procedures are employed in the use of personal protective clothing and
             respiratory protection

           Ensures personal physical readiness through proper nutrition, water intake, rest,
           and stress control techniques

           Supervises emergency decon procedures

           Supervises secondary decontamination for all MMST personnel.

           Supervises definitive decon procedures

           Reports any signs or symptoms of Critical Incident Stress in co-workers and
           advises the Team Medical Section Chief

           Keeps the Operations Section Chief apprised of any tactical accomplishments or
           conflicts, supply deficiencies, or equipment malfunctions/needs

           Thoroughly briefs shift replacement on all ongoing operations when being
           relieved at work cycle rotations


      (f) Demobilization:

           Assembles personnel for a team briefing on the mission status and
           reassignment/demobilization determinations



11/05/10                                                                                   3-95
                                                                                  City of Seattle
                                                                 Seattle Fire Department (SFD)
                                                    _Metropolitan Medical Strike Team (MMST )



           Ensures that assigned HazMat tools and equipment are inventoried, returned to
           the cache, and prepared for movement

           Notifies the Logistics Section of the losses or potential maintenance requirements
           of any tools and equipment

           Oversees the breakdown and policing of the operational area

           Oversees the packaging, movement, and loading of the equipment cache, when
           indicated


      (g) Post-incident:

           Reports any ill or unusual feelings or sicknesses that may be attributable to
           exposure at the incident

           Collects report from HazMat Specialist and submits final reports to Plans Section
           Chief for inclusion in the After-Action Report.

           Restores personal ‗‗GO‘‘ kit to deployment status

           Ensures the return of all items issued during the mobilization phase

           Upon return, ensures all personnel participate in the MMST mission critique and
           Critical Incident and Stress Management (CISM) session

           Section member will make contact with their employing agency to inform them
           of the termination of their participation in MMST activation and follow the time
           and attendance reporting requirements of their home jurisdiction.

E) Field Hazardous Materials (HAZMAT) Specialist

   (1) Introduction

           Field Hazardous Materials Specialists are responsible for the safe mitigation of
           NBC incidents in coordination with and support of local HAZMAT Teams. They
           will also coordinate with the Field Medical Specialists to safely extricate and
           provide medical care as directed to victims of these incidents. Field Hazardous
           Materials Specialists report to the Field HazMat Group Supervisor.




11/05/10                                                                                   3-96
                                                                                     City of Seattle
                                                                    Seattle Fire Department (SFD)
                                                       _Metropolitan Medical Strike Team (MMST )

   (2) The Field Hazardous Materials Specialists perform the following duties:

               Implements the HAZMAT action plan as specified by the Operations Section
                Chief

               Assists with product sampling and identification

               Conducts decon

               Performs additional tasks and duties as assigned during a mission

           Will be prepared to accept the assignment of unit leader


   (3) Operational Checklist

      (a) Prior to activation:

            Ensures ‗‗GO‘‘ kit is ready and available for deployment


      (b) Upon activation:

            Receives notification and instructions for arrival at the mobilization site

            Monitors disaster-related information from local sources


      (c) At mobilization site:

            Advises the Field HazMat Group Supervisor that he/she is present

            Assists with the transfer and loading of MMST equipment as necessary

            Receives necessary briefing information from the Operations Section Chief as
            time permits

            Assists in preparation for proceeding to the incident site

           Affixes appropriate functional identifier

            Brings personal ‗‗GO‘‘ kit




11/05/10                                                                                      3-97
                                                                                      City of Seattle
                                                                     Seattle Fire Department (SFD)
                                                        _Metropolitan Medical Strike Team (MMST )

      (d) In transit:

           Reviews the latest disaster information

           Reviews information pertinent to position description, operations, checklist,
           operational procedures, and safety procedures

           Initiates preliminary assigned tasks to the extent possible

           Takes advantage of travel time for rest prior to arrival


      (e) On-site operations:

            Assists with the setup of the Field HazMat Section

            Ensures personal physical readiness through proper nutrition, water intake, rest,
            and stress control techniques

            Assists entry team personnel (primary and backup) in donning PPE as directed

            Performs entry team functions as directed

            Performs patient extractions

            Assists in establishing, setting up, and operating in decon areas

            Provides medical care to injured civilians in accordance with the appropriate
            MMST Medical Protocol

            Performs other HazMat Section functions as directed

            Assists and coordinates with the Law Enforcement Liaison and the primary law
            enforcement agency in the collection and packaging of contaminated victim
            clothing and categorization and packaging of valuable personal belongings
            (watches, jewelry, wallets, purses, etc.), as appropriate

            Assists and coordinates with the Law Enforcement Liaison and the primary law
            enforcement agency in the packaging and processing of incident fatalities, as
            appropriate

            Briefs shift replacement fully on all ongoing operations when being relieved at
            work cycle rotations




11/05/10                                                                                       3-98
                                                                                      City of Seattle
                                                                     Seattle Fire Department (SFD)
                                                        _Metropolitan Medical Strike Team (MMST )

      (f) Demobilization:

           Assists in the breakdown of HazMat Operations Section upon completion of the
           incident as determined by the TFL

           Assures collection and return of equipment and supplies to Logistics Section

           Assures that contaminated materials and                equipment that cannot be
           decontaminated are properly disposed

           Reports any equipment losses or breakages to the Logistics Section

           Assists in the return of the equipment cache as directed


      (g) Post-incident:

           Reports any ill or unusual feelings or sicknesses that may be attributable to
           exposure at the incident

           Reports any operational deficiencies to the Field HazMat Group Supervisor

           Submits reports to Field HazMat Group Supervisor for inclusion in After-Action
           Report

           Attends after-action critiques as directed

           Ensures that personal ‗‗GO‘‘ kit is operationally ready for future missions

           Section members will make contact with their employing agency to inform them
           of the termination of their participation in MMST activation and follow the time
           and attendance reporting requirements of their home jurisdiction.




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                                                                                                                                                      City of Seattle
                                                                                                                                     Seattle Fire Department (SFD)
                                                                                                                        _Metropolitan Medical Strike Team (MMST )


                                                      Seattle Fire Department

                              METRO MEDICAL STRIKE TEAM      (Proposed 62 Person Team)




                                                                     TFL

                                                  Law Enforcement                    Safety
                                 Security             Liaison                        Officer


                                                      Medical                       Hospital
                                                      Director                      Liaison



                  OPERATIONS                        PLANS                                      LOGISTICS                     TEAM-MEDICAL
                   SECTION                         SECTION                                      SECTION                        SECTION
                     CHIEF                          CHIEF                                        CHIEF                          CHIEF


    Field-Medical (FM)      Field-HazMat (FH)        Plans                 Communications                   Logistics               TM - Unit 1
          Group                   Group             Group                      Group                         Group                 1 Unit Leader
        Supervisor              Supervisor         Supervisor                Supervisor                    Supervisor               1 Specialist

                                                                                                                                    TM - Unit 2
             FM - Unit 1           FH - Unit 1         Intelligence                 Comm Unit                 Log. Unit 1          1 Unit Leader
           1 Unit Leader         1 Unit Leader       Info - Specialist              1 Specialist             1 Unit Leader          1 Specialist
            5 Specialists         5 Specialists    (Law Enforcement)                                          1 Specialist

             FM - Unit 2           FH - Unit 2          HazMat                                                Log. Unit 2
           1 Unit Leader         1 Unit Leader      Info - Specialist                                        1 Unit Leader
            5 Specialists         5 Specialists        (Chemist)                                              1 Specialist

                                   FH - Unit 3          Medical
                                 1 Unit Leader      Info - Specialist
                                  5 Specialists      (Toxicologist)

                                   FH - Unit 4
                                 1 Unit Leader
                                  5 Specialists




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                                                                                   City of Seattle
                                                                  Seattle Fire Department (SFD)
                                                     _Metropolitan Medical Strike Team (MMST )



III. PLANS SECTION

    A) Plans Section Chief

   (1) Introduction

           The Plans Section Chief is responsible for assisting the Task Force Leader
           (TFL) and coordinating planning activities. As the TFL continually monitors
           the progress of the Team for effectiveness, the Plans Section Chief will ensure
           the documentation of MMST activities.

           The Plans Section Chief is responsible for fulfilling the Team Public
           Information Officer (PIO) function. This function in itself is complex;
           therefore, it is critical that contact be made with the local PIO early in the
           event.

           At the completion of missions, the Plans Section Chief will be responsible for
           gathering input from all section leaders for inclusion into the After-Action
           Report.

           The Plans Section Chief reports directly to the TFL.


   (2) The Plans Section Chief performs the following duties:

              Provides planning support for the TFL

              Records the sequence of events in designated MMS T documents

              Fulfills the PIO function for the Team

              Gathers input from Section Chiefs for development of the After-Action
               Report

              Coordinates with the Program Management Team review of the MMST
               plan for updating

              Assures that all medical, training, and other team member records are
               current

              Assures the review of mission-pertinent sensitive technical information
           from the Information Specialist in determining appropriate MMST
           distribution



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                                                                                  City of Seattle
                                                                 Seattle Fire Department (SFD)
                                                    _Metropolitan Medical Strike Team (MMST )

       Directs communication group when reassigned to Plans Section from Logistics




   (3) Operational Checklist

      (a) Prior to activation:

           Assures incident event log is ready for use

           Assures that MMST Operational System Description is administratively
           current

           Assures that all team members' medical, training, and other records are current

           Assures that predeveloped press releases are current and accurate

           Maintains all Federal/State/Local required records and documents

           Establishes team administrative file containing, but not limited to, forms, logs,
           and records necessary to administer the MMST

           Ensures personal ''GO'' kit is available and ready for deployment


      (b) Upon activation:

           Develops MMST portion of the Incident Action Plan

           Receives notification of assignment and team mobilization location

           Reports to mobilization location

           Gathers disaster-related information from local sources to assist TFL in initial
           MMST briefing

           Assembles the necessary documents for team deployment for subsequent
           forwarding to    the appropriate representatives


      (c) At mobilization site:

      Affixes appropriate functional identifier

      Determines all assigned Plans Section members are present


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                                                                                  City of Seattle
                                                                 Seattle Fire Department (SFD)
                                                    _Metropolitan Medical Strike Team (MMST )



      Brings personal ''GO'' kit

      Notifies TFL of arrival

      Receives TFL briefing

      In coordination with Law Enforcement Liaison, ensures best route of travel for
      MMST team and cache


      (d) In transit:

      Monitors incident on primary communications channel

      Reviews information pertinent to their position description and ensures personnel
      assigned to Plans Section reviews information pertinent to their position
      description

      Reviews PIO guidelines


      (e)       On-site operations:

            Assists the TFL in determining the MMST operating area

            Assembles with local PIO to coordinate information release and dissemination

            Assures incident documentation is completed

            Assures that pertinent MMST activities are recorded

            In coordination with the local PIO, establishes a Joint Information Center
            (JIC) through which all information concerning the event will be released

            Assures the coordination between the Information Specialists

            Ensures personal physical readiness through proper nutrition, water intake,
            rest, and stress control techniques

            Performs other duties and assignments as determined by the TFL

            Briefs shift replacement fully on all ongoing operations when being relieved
            at work cycle rotations




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                                                                                 City of Seattle
                                                                Seattle Fire Department (SFD)
                                                   _Metropolitan Medical Strike Team (MMST )

           Directs communication group when reassigned to Plans Section from
           Logistics

      (f) Demobilization:

           Returns issued items to Logistics personnel

           Assembles for a Team briefing on mission status and reassignment and
           demobilization determination

           Collects section reports from section officers for compilation into the After-
           Action Report

           Assures confidentiality of all MMST reports


      (g) Post-incident:

           Reports any ill or unusual feelings or sicknesses that may be attributable to
           exposure at the incident

           Submits After-Action Report

           Assures Plans cache is returned to deployment status

           Restores personnel ''GO'' kit to deployment status

           Section member will make contact with their employing agency to inform them
           of the termination of their participation in MMST activation and follow the time
           and attendance reporting requirements of their home jurisdiction.




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                                                                                      City of Seattle
                                                                     Seattle Fire Department (SFD)
                                                        _Metropolitan Medical Strike Team (MMST )



B) Plans Group Supervisor

   (1) Introduction

      The Plans Group Supervisor is responsible for the coordination of the
   Technical Information Specialists and documentation of MMST activities. The
   Plans Group Supervisor is responsible for assisting the Plans Section Chief in
   coordinating MMST planning activities. At the completion of missions, the
   Plans Group Supervisor will be responsible for gathe ring input from the
   Technical Information Specialists for inclusion into the After-Action Report.


   (2) The Plans Group Supervisor performs the following duties:

              Provides planning support for the Plans Section Chief

              Records the sequence of events in designated MMST documents

              Coordinates with the Plans Section Chief a review of the MMST plan for
               updating

              Ensures that all medical, training, and other team member records are
               current

               Works with the Plans Section Chief on reviewi ng mission-pertinent sensitive
           technical i nformation from Informati on S peci alists in determini ng appropriate MMS T
           distri bution

          Gathers input from Technical Information Specialists for development of the
           After-Action Report

              Will assume the role of Plans Section Chief when needed


   (3) Operational Checklist

      (a) Prior to activation:

           Ensures incident event log is ready for use

           Ensures that MMST Operational System Description is administratively
           current

           Ensures that all team members' medical, training, and other records are current



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                                                                                   City of Seattle
                                                                  Seattle Fire Department (SFD)
                                                     _Metropolitan Medical Strike Team (MMST )

           Ensures that predeveloped press releases are current and accurate

           Provides the Plans Section Chief with the information for formulation of the
           MMST portion of the Incident Action Plan

           Works with the Plans Section Chief to maintain all Federal/State/Local
           required records and documents

           Works with the Plans Section Chief to establish team administrative file
           containing, but not limited to, forms, logs, and records necessary to administer
           the MMST

           Ensures personal ''GO'' kit is available and ready for deployment


      (b) Upon activation:

           Receives notification of assignment and team mobilization location

           Assist the Plans Section Chief with the development of the MMST Incident
           Action Plan

           Reports to mobilization location

           Gathers disaster-related information from local sources to assist TFL in initial
           MMST briefing

           Assembles the necessary documents for team deployment for subsequent
           forwarding to    the appropriate representatives

           Works with Plans Section Chief to assemble the necessary documents


      (c) At mobilization site:

           Affixes appropriate functional identifier

           Brings personal ''GO'' kit

           Notifies Plans Section Chief of arrival

           Ensures all Information Specialists are present

           Receives TFL briefing




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                                                                                  City of Seattle
                                                                 Seattle Fire Department (SFD)
                                                    _Metropolitan Medical Strike Team (MMST )



      (d) In transit:

           Monitors incident on primary communications channel

           Reviews information pertinent to their position description and ensures
           personnel assigned to Plans Section reviews information pertinent to their
           position description


      (e) On-site ope rations:

           Assists the Plans Section Chief in determining an assigned operating area

           Assembles with local PIO to coordinate information release and dissemination

           Ensures incident documentation is completed

           Has primary responsibility to ensure the recording of pertinent MMST
           activities

           Coordinates information received from Information Specialists for use by the
           MMST

           Ensures personal physical readiness through proper nutrition, water intake,
           rest, and stress control techniques

           Performs other duties and assignments as determined by the Plans Section
           Chief

           Briefs shift replacement fully on all ongoing operations when being relieved
           at work cycle rotations


      (f) Demobilization:

           Returns issued items to Logistics Section

           Assembles for a Team briefing on mission status and reassignment and
           demobilization determination

           Assists in the collection of section reports from section officers for
           compilation into the After-Action Report




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                                                                                     City of Seattle
                                                                    Seattle Fire Department (SFD)
                                                       _Metropolitan Medical Strike Team (MMST )

              Assembles reports from the Information Specialists for inclusion in the After-
              Action Report

              Maintains confidentiality of all MMST reports


        (g) Post-incident:

              Reports any ill or unusual feelings or sicknesses that may be attributable to
              exposure at the incident

              Assists in the preparation of the After-Action Report

              Ensures Plans cache is returned to deployment status

              Restores personnel ''GO'' kit to deployment status

              Section member will make contact with their employing agency to inform them
              of the termination of their participation in MMST activation and follow the time
              and attendance reporting requirements of their home jurisdiction.


C)          Intelligence Information Specialist

     (1) Introduction

              The Intelligence Information Specialist will be a Law Enforcement Officer,
              usually of sergeant rank or higher. The Intelligence Information Specialist is
              responsible for assisting in the coordination of the MMST intelligence activities
              and the coordination of intelligence information to assist in the mitigation of the
              incident.


     (2) The Intelligence Information Specialist performs the following duties:

             Obtain pertinent law enforcement information in accordance with the City of
              Seattle Ordinance #108333, ―Collection of Information for Law Enforcement
              Purposes‖ from the following:

              -   FBI field office
              -   Local law enforcement agencies
              -   Local fire and rescue agencies including HAZMAT teams.
              -   Local Emergency Operations Centers
              -   Pertinent NBC information discussed at intelligence sharing forums




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                                                                                     City of Seattle
                                                                    Seattle Fire Department (SFD)
                                                       _Metropolitan Medical Strike Team (MMST )

           -   Current national and international events and/or terrorist group activities by
               any media available

          Advises the Plans Group Supervisor concerning law enforcement related issues
           and latest intelligence information

          Interfaces with the Information Specialists to ensure the coordination and
           consolidation of information

          Becomes familiar with local law enforcement resources available in each
           jurisdiction

          Immediately communicates any information pertaining to the safety and security
           for the MMST

          Maintains confidentiality of all incident information


   (3) Operational Checklist

      (a) Prior to activation:

           Ensures personal ‗‗GO‘‘ kit is ready and available for deployment

      (b) Activation:

           Receives notification and instructions for arrival at mobilization site

           Monitors disaster-related information from local sources


      (c) At mobilization site:

           Advises Plans Group Supervisor of arrival and receives briefing

           Affixes appropriate functional identifier

           Receives TFL briefing

           Bring personal ‗‗GO‘‘ kit


      (d) In transit:

           Reviews the latest disaster information


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                                                                                    City of Seattle
                                                                   Seattle Fire Department (SFD)
                                                      _Metropolitan Medical Strike Team (MMST )



           Reviews information pertinent to position description, operations checklist,
           operational procedures, and safety procedures

           Takes advantage of travel time for rest prior to arrival

           If on duty, notifies their employing agency of the MMST activation


      (e) On-site operations:

           Ensures personal physical readiness through proper nutrition, water intake, rest,
           and stress control techniques

           Gathers and disseminates preliminary and additional intelligence information
           with the Law Enforcement Liaison and relays this information to the Plans Group
           Supervisor, as appropriate

           Meets with Law Enforcement Liaison and is briefed on current law enforcement
           issues and plans


      (f) Demobilization:

           Assists with the demobilization of the Plans Section

           Assembles for team briefing or mission status and reassignment/demobilization
           determinations

           Ensures all issued items are returned to the Logistics Section

           Logistics Section will be notified of the loss or potential maintenance
           requirements of any tools and equipment.


      (g) Post-incident:

           Reports any ill or unusual feelings or sicknesses that may be attributable to
           exposure at the incident

           Submits reports to Plans Group Supervisor for inclusion in the After-Action
           Report




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                                                                                    City of Seattle
                                                                   Seattle Fire Department (SFD)
                                                      _Metropolitan Medical Strike Team (MMST )

           Section member will make contact with their employing agency to inform them
           of the termination of their participation in MMST activation and follow the time
           and attendance reporting requirements of their home jurisdiction

           Attends incident debriefing and CISM session

           Restores ‗‗GO‘‘ kit to deployment status




11/05/10                                                                                    3-111
                                                                                 City of Seattle
                                                                Seattle Fire Department (SFD)
                                                   _Metropolitan Medical Strike Team (MMST )



D) HazMat Information Specialist

   (1) Introduction

           The HazMat Information Specialist is responsible for coordinating all the MMST
           HazMat Information/Research activities including product/agent identification,
           research on agent management information, and mitigation information. The
           HazMat Information Specialist reports directly to the Plans Group Supervisor.


   (2) The HazMat Information Specialist will perform the following duties:

              Will coordinate with the Medical Information Specialist all product/agent
               research and identification activities of the MMST

              Will interact with consultants, assists with product identification, and
               managing research activities

              Interfaces with the Information Specialists to ensure the coordination and
               consolidation of information

              Will disseminate product information to the Plans Group Supervisor

              Keeps the Plans Section Supervisor updated on management information
               problems and section activities

              Works with the Field HazMat Group Supervisor on mitigation options

              Works with the Law Enforcement Liaison and primary law enforcement
               agency on security and evidence preservation

              Works with the Logistics Section to ensure adequate equipment and supplies
               are available for the HazMat Information Specialist Section


   (3) Operational Checklist

      (a) Prior to activation:

           Ensures ‗‗GO‘‘ kit is ready and available for deployment

      (b) Upon activation:

           Receives notification and reports to designated mobilization point


11/05/10                                                                                 3-112
                                                                                     City of Seattle
                                                                    Seattle Fire Department (SFD)
                                                       _Metropolitan Medical Strike Team (MMST )



           Monitors disaster-related information from local resources


      (c) At mobilization site:

           Advises Plans Group Supervisor of arrival

           Affixes appropriate functional identifier

           Receives TFL briefing

           Brings personal ‗‗GO‘‘ kit


       (d) In transit:

           Initiates preliminary product research in conjunction with ChemTrek, DoD, and
           other appropriate agencies

           Updates Plans Group Supervisor on preliminary product information and proper
           personal protective equipment (PPE)

           Reviews the latest disaster information

           Reviews information pertinent to position description, operations, checklist,
           operational procedures, and safety procedures.

           Initiates preliminary assigned tasks to the extent possible

           Takes advantage of travel time for rest prior to arrival


      (e) On-site operations:

           Ensures personal physical readiness through proper nutrition, water intake, rest,
           and stress control techniques

           Receives briefing from TFL

           Initiates an effort to rapidly identify vital product information by all available
           means (e.g., books, computers, consultants)

           Communicates research information to Plans Group Supervisor, Operations
           Section Chief and the Field HazMat Group Supervisor



11/05/10                                                                                     3-113
                                                                                     City of Seattle
                                                                    Seattle Fire Department (SFD)
                                                       _Metropolitan Medical Strike Team (MMST )



           Coordinates off-site product identification activities with Plans Group Supervisor

           Coordinates product transport off-site to identification facilities in conjunction
           with the Law Enforcement Liaison and the primary law enforcement agency

           Coordinates communications with appropriate resources regarding agent
           information to include:

                 Product Information
                 Product Identification
                 Product Mitigation
                 Information for release to public and media

           Briefs shift replacement fully on all ongoing operations when being relieved at
           work cycle rotations


      (f) Demobilization:

           Assists with the breakdown of the Plans Section

           Ensures collection and return of equipment and supplies to Logistics Section

           Assist Plans personnel with returning MMST cache as directed


      (g) Post-incident:

           Reports any ill or unusual feelings or sicknesses that may be attributable to
           exposure at the incident

           Attends mission critique and CISM session

           Restores ‗‗GO‘‘ kit to deployment status.

           Submits reports to Plans Group Supervisor for inclusion in the After-Action
           Report

           Ensures assigned equipment is operational for the next mission

           Section member will make contact with their employing agency to inform them
           of the termination of their participation in MMST activation and follow the time
           and attendance reporting requirements of their home jurisdiction.




11/05/10                                                                                     3-114
                                                                                 City of Seattle
                                                                Seattle Fire Department (SFD)
                                                   _Metropolitan Medical Strike Team (MMST )



E) Medical Information Specialist

   (1) Introduction

           The Medical Information Specialist is responsible for coordinating all the MMST
           Medical Information/Research activities including product/agent identification,
           research on clinical management information, antidote and mitigation
           information. The Medical Information Specialist reports directly to the Plans
           Group Supervisor.


   (2) The Medical Information Specialist will perform the following duties:

              Will coordinate with the HazMat Information Specialist all product/agent
               research and identification activities of the MMST

              Will interact with consultants, assists with product identification, and
               managing research activities

              Interfaces with the Information Specialists to ensure the coordination and
               consolidation of information

              Will disseminate product information to the Plans Group Supervisor

              Keeps the Plans Section Chief updated on management information problems
               and section activities

              Works with the Field Medical Group Supervisor and the Team Medical
               Section Chief on patient care activities and mitigation options

              Works with the Law Enforcement Liaison and the primary law enforcement
               agency on security and evidence preservation

              Works with the Logistics Section to ensure adequate equipment and supplies
               are available for the Medical Information Specialist Section


   (3) Operational Checklist

      (a) Prior to activation:

           Ensures ‗‗GO‘‘ kit is ready and available for deployment




11/05/10                                                                                 3-115
                                                                                     City of Seattle
                                                                    Seattle Fire Department (SFD)
                                                       _Metropolitan Medical Strike Team (MMST )

      (b) Upon activation:

           Receives notification and reports to designated mobilization point

           Monitors disaster-related information from local resources


      (c) At mobilization site:

           Advises Plans Group Supervisor of arrival

           Receives TFL briefing

           Affixes appropriate functional identifier

           Brings personal ‗‗GO‘‘ kit


      (d) In transit:

           Initiates preliminary product research in conjunction with Poison Control Center

           Updates Plans Group Supervisor on preliminary product information, proper
           personal protective equipment (PPE), and medical management
           recommendations

           Reviews the latest disaster information

           Reviews information pertinent to position description, operations, checklist,
           operational procedures, and safety procedures.

           Initiates preliminary assigned tasks to the extent possible

           Takes advantage of travel time for rest prior to arrival


      (e) On-site operations:

           Ensures personal physical readiness through proper nutrition, water intake, rest,
           and stress control techniques

           Receives briefing from TFL

           Initiates an effort to rapidly identify vital product information by all available
           means (e.g., books, computers, and consultants)



11/05/10                                                                                     3-116
                                                                                     City of Seattle
                                                                    Seattle Fire Department (SFD)
                                                       _Metropolitan Medical Strike Team (MMST )



           Communicates research information to Plans Group Supervisor and Medical
           Director

           Coordinates off-site product identification activities with Plans Group Supervisor
           and Medical Director

           Coordinates product transport off-site to identification facilities in conjunction
           with the Law Enforcement Liaison and the primary law enforcement agency

           Coordinates medical consultation with Poison Control Center including:

                 Patient signs/symptoms
                 Product information
                 Product Identification
                 Information for release to public and media

           Briefs shift replacement fully on all ongoing operations when being relieved at
           work cycle rotations


      (f) Demobilization:

           Assists with the breakdown of the Plans Section

           Ensures collection and return of equipment and supplies to Logistics Section

           Assist Plans personnel with returning MMST cache as directed


      (g) Post-incident:

           Reports any ill or unusual feelings or sicknesses that may be attributable to
           exposure at the incident

           Attends mission critique and CISM session

           Restores ‗‗GO‘‘ kit to deployment status.

           Submits reports to Plans Group Supervisor for inclusion in the After-Action
           Report

           Ensures assigned equipment is operational for the next mission




11/05/10                                                                                     3-117
                                                                                 City of Seattle
                                                                Seattle Fire Department (SFD)
                                                   _Metropolitan Medical Strike Team (MMST )

           Section member will make contact with their employing agency to inform them
           of the termination of their participation in MMST activation and follow the time
           and attendance reporting requirements of their home jurisdiction.




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                                                                                                                                                             City of Seattle
                                                                                                                                            Seattle Fire Department (SFD)
                                                                                                                               _Metropolitan Medical Strike Team (MMST )



                                                        Seattle Fire Department

                                METRO MEDICAL STRIKE TEAM      (Proposed 62 Person Team)




                                                                       TFL

                                                    Law Enforcement                    Safety
                                   Security             Liaison                        Officer


                                                        Medical                       Hospital
                                                        Director                      Liaison



                    OPERATIONS                        PLANS                                      LOGISTICS                        TEAM-MEDICAL
                     SECTION                         SECTION                                      SECTION                           SECTION
                       CHIEF                          CHIEF                                        CHIEF                             CHIEF


       Field-Medical (FM)     Field-HazMat (FH)        Plans                 Communications                   Logistics                 TM - Unit 1
             Group                  Group             Group                      Group                         Group                   1 Unit Leader
           Supervisor             Supervisor         Supervisor                Supervisor                    Supervisor                 1 Specialist

                                                                                                                                        TM - Unit 2
               FM - Unit 1           FH - Unit 1         Intelligence                 Comm Unit                 Log. Unit 1            1 Unit Leader
             1 Unit Leader         1 Unit Leader       Info - Specialist              1 Specialist             1 Unit Leader            1 Specialist
              5 Specialists         5 Specialists    (Law Enforcement)                                          1 Specialist

               FM - Unit 2           FH - Unit 2          HazMat                                                Log. Unit 2
             1 Unit Leader         1 Unit Leader      Info - Specialist                                        1 Unit Leader
              5 Specialists         5 Specialists        (Chemist)                                              1 Specialist

                                     FH - Unit 3          Medical
                                   1 Unit Leader      Info - Specialist
                                    5 Specialists      (Toxicologist)

                                     FH - Unit 4
                                   1 Unit Leader
                                    5 Specialists




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                                                                                    City of Seattle
                                                                   Seattle Fire Department (SFD)
                                                      _Metropolitan Medical Strike Team (MMST )



IV. LOGISTICS SECTION

    A) Logistics Section Chief

   (1) Introduction

           The Logistics Section Chief is responsible for overseeing the management of the
           equipment cache and the communications section of the MMST. The Logistics
           Section Chief reports directly to the Task Force Leader.


   (2) The Logistics Section Chief will perform the following duties:

          Assures the equipment caches is in a state of readiness at all times

          Assures cache gets to designated mobilization point or incident location

          Supervises the packaging, transport, distribution, and maintenance of the MMST
           equipment cache

          Coordinates with military and civilian transport officials for all cache logistics

          Procures items, either during the mobilization phase or on-site, as appropriate

          Obtains medical equipment and pharmaceuticals from designated local and
           regional facilities

          Assures the security and accountability of all components of the MMST
           equipment cache

          Maintains appropriate records and reports

          Performs additional tasks or duties as assigned during a mission


   (3) Operational Checklist

      (a) Prior to activation:

           Ensures personal ―GO‖ kit is ready and available for deployment

      (b) Upon activation:

           Receives notification and reports to designated mobilization point


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                                                                                     City of Seattle
                                                                    Seattle Fire Department (SFD)
                                                       _Metropolitan Medical Strike Team (MMST )



           Monitors disaster-related information from local resources


      (c) At mobilization site:
           Advises TFL of arrival

           Inventories and supervises the transfer and loading of the MMST equipment
           cache

           Receives TFL briefing

           Ensures all section members are present

           Implements property accountability procedures

           Assists in the departure to the incident site or assignment destination

           Affixes appropriate functional identifier

           Brings personal ‗‗GO‘‘ kit

           If air transport is used, supervises the movement and loading of equipment in
           coordination with the civilian airport authorities, military loadmaster, and cargo
           handlers. Obtains and maintains copies of all manifests


   (d) In transit:

           Reviews the latest disaster-related information as it becomes available

           Reviews information pertinent to position description, operational checklist,
           operational procedures, and safety procedures

           Takes full advantage of available travel time for rest prior to arrival

      (e) On-site operations:

           Ensures personal physical readiness through proper nutrition, water intake, rest,
           and stress control techniques

           Coordinates with the TFL for selection of an appropriate site for the equipment
           cache staging area and base setup




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                                                                                   City of Seattle
                                                                  Seattle Fire Department (SFD)
                                                     _Metropolitan Medical Strike Team (MMST )

           Supervises the unloading, sorting, and setup of the equipment cache and the
           MMST support facilities

           Receives initial briefing of tactical assignment from TFL or designee, including:

           -   Incident situation report
           -   MMST objectives
           -   Tactical assignments
           -   MMST support layout and requirements (Base of Ops)
           -   Briefing on the communications plan, frequencies, and radio designations
           -   Reviews emergency signaling/evacuation procedures
           -   Reviews medical treatment and evacuation procedures
           -   Reviews the process for ordering supplies and equipment


           Establishes the equipment cache staging area including:

           -   Categorizes equipment and supplies
           -   Assures the environmental protection of appropriate supplies and equipment
           -   Coordinates the appropriation of fuels, compressed air, and medical oxygen
           -   Assures fuel equipment and tools; tests and makes ready for operation
           -   Coordinates security for the equipment cache. Coordinates with Team
               Medical Section Chief to assure security and accountability of controlled
               medical drugs
           -   Establishes work area for maintenance/repair


           Implements property accountability and equipment/tool supply system

           Carries out tactical assignments as directed.

           Assures the use of all safety practices and procedures

           Provides support as necessary for MMST requirements for on-site equipment
           support

           Ensures physical readiness through proper nutrition, water intake, rest, and stress
           control techniques

           Keeps the TFL apprised of any tactical accomplishments or conflicts; supplies
           deficiencies or equipment malfunctions

           Briefs shift replacement fully on all ongoing operations when relieved at work
           cycle rotations




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                                                                   Seattle Fire Department (SFD)
                                                      _Metropolitan Medical Strike Team (MMST )

           Participates in the MMST briefings


      (f) Demobilization:

           Assembles for a team briefing on                     the     mission     status    and
           reassignment/demobilization determinations

           Assures that all cache tools and equipment are inventoried, returned to the cache,
           and prepared for movement

           Prepares personal belongings for demobilization

           Tracks and maintains a listing of the losses or potential maintenance issues of all
           tools and equipment

           Supervises the breakdown and policing of the MMST operational area

           Supervises the packaging, movement, and loading of the equipment cache

           Submits reports to the Plans Section Chief for inclusion in the After-Action
           Report


      (g) Post-incident:

           Reports any ill or unusual feelings or sicknesses that may be attributable to
           exposure at the incident

           Upon return, ensures all section personnel participate in the MMST mission
           critique and CISM debriefing

           Restores ‗‗GO‘‘ kit to deployment status

            Assures Logistics Section equipment is operational for the next mission
           Works with TFL to ensure entire MMST cache is restored to readiness for next
           deployment

           Section member will make contact with their employing agency to inform them
           of the termination of their participation in MMST activation and follow the time
           and attendance reporting requirements of their home jurisdiction.




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                                                                                   City of Seattle
                                                                  Seattle Fire Department (SFD)
                                                     _Metropolitan Medical Strike Team (MMST )



 B) Logistics Group Supervisor

   (1) Introduction

           The Logistics Group Supervisor is responsible for managing the Logistics Units
           who maintain the equipment cache for the MMST. The Logistics Group
           Supervisor reports directly to the Logistics Section Chief.


   (2) The Logistics Group Supervisor will perform the following duties:

          Maintains the equipment cache in a state of readiness at all times

          Assures correct packaging, transport, distribution, and maintenance of the MMST
           cache during mission assignments

          Assures the security and accountability of all components of the cache

          Maintains appropriate records and reports

          Performs additional tasks or duties as assigned


   (3) Operational Checklist

      (a) Prior to activation:

           Ensures that personal ‗‗GO‘‘ kit is ready for deployment

           Identifies cache maintenance problems and recommends corrective action

           Maintains a current computerized and hard copy inventory listing of all
           equipment and supplies

           Assures that all equipment testing is current and in compliance with appropriate
           Local, State, and Federal guidelines

           Assures equipment cache inventory is in a constant state of readiness


      (b) Upon activation:

           Receives notification and reports to designated mobilization point
           Monitors disaster-related information from local resources


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                                                                    Seattle Fire Department (SFD)
                                                       _Metropolitan Medical Strike Team (MMST )




      (c) At mobilization site:

           Ensures that the vehicle containing equipment cache is ready to deploy

           Ensures familiarity with the incident location and route of travel, per Plans
           Section Chief‘s direction

           Ensures personal physical readiness through proper nutrition, water intake, rest,
           and stress control techniques

           Notifies Logistics Section Chief of arrival

           Departs for incident site upon direction from Logistics Section Chief

           Affixes appropriate functional identifier

           Brings personal ‗‗GO‘‘ kit


      (d) On-site operations:

             Directs and conducts the off-loading of MMST cache

             Establishes cache setup in MMST designated area

             Coordinates distribution of cache to various sections

             Keeps records on various equipment and supplies being issued to MMST
             personnel

             Carries out tactical assignments as directed

             Ensures the use of all safety practices and procedures

             Keeps the Logistics Section Chief apprised of any equipment deficiencies or
             malfunctions

             Provides equipment repair and maintenance

              Briefs shift replacement fully on all ongoing operations when being relieved at
              work cycle rotations




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                                                                Seattle Fire Department (SFD)
                                                   _Metropolitan Medical Strike Team (MMST )

      (e) Demobilization:

           Ensures that all equipment is returned to the cache

           Assists with the breakdown and policing of the MMST operational area

           Ensures all equipment is properly decontaminated before returning to the cache

           Ensures proper disposal of contaminated items that cannot be decontaminated

           Coordinates the reloading of the equipment cache for return home


      (f) Post-incident:

           Reports any ill or unusual feelings or sicknesses that may be attrib utable to
           exposure at the incident

           Participates in the MMST mission critique and Critical Incident and Stress
           Management (CISM) session

           Ensures needed repairs and preventive maintenance are done on all items
           before being returned to the cache for the next deployment

           Identifies and documents all operational losses or expendables for subsequent
           replacement or repair (if repairable)

           Submits reports to the Logistics Section Chief for inclusion in the After-Action
           Report

           Restores ‗‗GO‘‘ kit to deployment status

           Section member will make contact with their employing agency to inform them
           of the termination of their participation in MMST activation and follow the
           time and attendance reporting requirements of their home jurisdiction.




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                                                                  Seattle Fire Department (SFD)
                                                     _Metropolitan Medical Strike Team (MMST )



C) Logistics Specialist

   (1) Introduction

           The Logistics Specialists are responsible for directly managing the equipment
           cache for the MMST. The Logistics Specialists report directly to the Logistics
           Group Supervisor.


   (2) The Logistics Specialist will perform the following duties:

          Is responsible for maintaining the equipment cache in a state of readiness at all
           times

          Is responsible for the correct packaging, transport, distribution, and maintenance
           of the MMST cache during mission assignments

          Is responsible for the security and accountability of all components of the cache

          Is responsible for maintaining appropriate records and reports

          Will be prepared to accept the assignment of unit leader

          Is responsible for performing additional tasks or duties as assigned


   (3) Operational Checklist

       (a) Prior to activation:

           Ensures that personal ‗‗GO‘‘ kit is ready for deployment

           Identifies cache maintenance problems and recommends corrective action

           Maintains a current computerized and hard copy inventory listing of all
           equipment and supplies

           Assures that all equipment testing is current and in compliance with appropriate
           local, State, and national guidelines

           Ensures equipment cache inventory is in a constant state of readiness for
           deployment




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                                                                                     City of Seattle
                                                                    Seattle Fire Department (SFD)
                                                       _Metropolitan Medical Strike Team (MMST )



      (b) Upon activation:

           Receives notification and reports to designated mobilization point

           Monitors disaster-related information from local resources


      (c) At mobilization site:

           Ensures that the vehicle containing equipment cache is ready to deploy

           Ensures familiarity with the incident location and route of travel, per Plans
           Section Chief‘s direction

           Ensures personal physical readiness through proper nutrition, water intake, rest,
           and stress control techniques

           Notifies Logistics Group Supervisor of arrival

           Departs for incident site upon direction from Logistics Section Chief

           Affixes appropriate functional identifier

           Brings personal ‗‗GO‘‘ kit


      (d) On-site operations:

             Directs and conducts the off-loading of MMST cache

             Establishes cache setup in MMST designated area

             Coordinates distribution of cache to various sections

             Keeps records on various equipment and supplies being issued to MMST
             personnel

             Carries out tactical assignments as directed

             Ensures the use of all safety practices and procedures

             Keeps the Logistics Group Supervisor apprised of any equipment deficiencies
             or malfunctions




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                                                                                 City of Seattle
                                                                Seattle Fire Department (SFD)
                                                   _Metropolitan Medical Strike Team (MMST )

           Provides equipment repair and maintenance

           Briefs shift replacement fully on all ongoing operations when being relieved at
           work cycle rotations


      (e) Demobilization:

           Ensures that all equipment is returned to the cache

           Assists with the breakdown and policing of the MMST operational area

           Ensures all equipment is properly decontaminated before returning to the cache

           Ensures proper disposal of contaminated items that cannot be decontaminated

           Coordinates the reloading of the equipment cache for return home


      (f) Post-incident:

           Reports any ill or unusual feelings or sicknesses that may be attributable to
           exposure at the incident

           Participates in the MMST mission critique and Critical Incident a nd Stress
           Management (CISM) session

           Ensures needed repairs and preventive maintenance are done on all items
           before being returned to the cache for the next deployment

           Identifies and documents all operational losses or expendables for subsequent
           replacement or repair (if repairable)

           Submits reports to the Logistics Group Supervisor for inclusion in the After-
           Action Report

           Restores ‗‗GO‘‘ kit to deployment status

           Section members will make contact with their employing agency to inform
           them of the termination of their participation in MMST activation and follow
           the time and attendance reporting requirements of their home jurisdiction.




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                                                                                  City of Seattle
                                                                 Seattle Fire Department (SFD)
                                                    _Metropolitan Medical Strike Team (MMST )



D) Communications Group Supe rvisor

   (1) Introduction

            The Communications Group Supervisor is responsible for managing the
            communications system for the MMST. The Communications Group
            Supervisor reports directly to the Logistics Section Chief. The
            Communications Group may be reassigned to the Plans Section during an
            incident.

   (2)      The Communications Supervisor performs the following duties:

               Assesses overall needs and develops the incident communications plan

               Is responsible for frequency management, installation, operation, and
                maintenance of the MMST communications system

               Coordinates communications with other appropriate entities

               Is responsible for the accountability of all components of the MMST
                communications system

               Maintains appropriate records and reports

               Performs additional tasks or duties as assigned during a mission


   (3) Operational Checklist

         (a) Prior to activation:

         Ensures personal ''GO'' kit is available and prepared for deployment

         Ensures all communications equipment is fully operational


         (b) Upon activation:

         Monitors disaster-related information from local sources

         Issues communications radio equipment to MMST personnel and:

                 Identifies the assigned frequency(ies)
                 Briefs members on accountability, use, and care


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                                                                                  City of Seattle
                                                                 Seattle Fire Department (SFD)
                                                    _Metropolitan Medical Strike Team (MMST )

               Ensures personnel are aware of the prohibition of the use of radios
                where indicated


      (c) At mobilization site:

      Advises Logistics Section Chief of arrival

      Ensures Communications Specialist is present

      Assembles for a MMST briefing from the TFL

      Assists with the movement and loading of equipment

      Affixes appropriate functional identifier

      Brings personal ''GO'' kit


      (d) In transit:

           Reviews the latest disaster-related information as available

           Reviews information pertinent to position description, operational checklist,
           operational procedures, and safety procedures

           Takes advantage of available travel time for rest prior to arrival

           Discusses the formulation of the communications plan with the Plans Section
           Chief

      (e) On-site ope rations:

           Ensures personal physical readiness through proper nutrition, water intake,
           rest, and stress control techniques

           Provides for communications equipment security and protection from the
           elements

           Assists the Logistics Specialists with the unloading, sorting and setup of the
           communications equipment cache

           Establishes communications with Local Incident Command Structure




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                                                                                 City of Seattle
                                                                Seattle Fire Department (SFD)
                                                   _Metropolitan Medical Strike Team (MMST )

           Determines on-site operating frequencies. Initiates the development of the
           communications plan

           Determines medivac communications capabilities. Identifies other
           communications systems that could enhance operations

           Receives initial briefing of tactical assignment from the TFL or des ignee
           including:

              Incident situation report
              MMST objectives
              Tactical assignments
              MMST support layout and requirements (Base of Operations)
              Review of emergency signaling and evacuation procedures
              Review of medical treatment and evacuation procedures
              Review of the process for ordering supplies and equipment
              Possible reassignment to Plans Section during an incident

           Briefs MMST personnel on the MMST communications plan

           Sets up communications system for MMST operations. Establishes schedule
           for communications center coverage. Implements equipment accountability
           system.

           Maintains Communication Log

           Tracks the location of MMST personnel

           Carries out tactical assignments as directed

           Anticipates requirements and evaluates the communications system
           effectiveness. Modifies to meet changing operational needs.

           Monitors MMST communications for compliance with established procedures

           Monitors electrical and battery supply status and provides replacements as
           necessary. Inventories and reorders as needed

           Ensures physical readiness through proper nutrition, water intake, rest, and
           stress control techniques

           Reports any signs or symptoms of personal critical incident stress in
           coworkers and advises the Team Medical Section Chief




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                                                                                 City of Seattle
                                                                Seattle Fire Department (SFD)
                                                   _Metropolitan Medical Strike Team (MMST )

           Keeps the Logistics Section Chief apprised of any tactical accomplishments or
           conflicts, supplies deficiencies, or equipment malfunctions

           Briefs shift replacement fully on all ongoing operations when relieved at work
           cycle rotations

      Participates in the MMST daily briefings


(f) Demobilization:

           Assembles for a Team briefing on the mission status and
           reassignment/demobilization determinations

           Ensures that assigned tools and equipment are inventoried, returned to the
           cache, and prepared for movement. Ensures that all communications
           equipment is properly cleaned, decontaminated, calibrated, and repackaged
           for transport

           Assists with the packaging, movement, and loading of the communications
           equipment cache

           Notifies the Logistics Group Supervisor of the losses or potential maintenance
           requirements of any tools and equipment

           Assists with the breakdown and policing of the MMST operational area


      (g) Post-incident:

           Reports any ill or unusual feelings or sicknesses that may be attributable to
           exposure at the incident

           Submits reports to the Logistics Section Chief for inclusion in the After-
           Action Report.

           Ensures the return of all items issued to Communications Group Supervisor
           during the mobilization phase. Ensures that all issued radios are returned to
           the cache

           Ensures communication equipment is ready for next deployment

           Upon return, participates in the MMST mission critique and CISM debriefing

           Restores personal ―GO‖ kit to deployment status



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                                                                                 City of Seattle
                                                                Seattle Fire Department (SFD)
                                                   _Metropolitan Medical Strike Team (MMST )



           Section members will make contact with their employing agency to inform them
           of the termination of their participation in MMST activation and follow the time
           and attendance reporting requirements of their home jurisdiction.




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                                                                                 City of Seattle
                                                                Seattle Fire Department (SFD)
                                                   _Metropolitan Medical Strike Team (MMST )

E) Communications Specialist

   (1) Introduction

           The Communications Specialist maintains the communications system for the
           MMST. The Communications Specialist reports directly to the
           Communications Group Supervisor.


   (2) The Communications Specialist performs the following duties:

              Assesses overall needs and assists in the development the incident
               communications plan

              Is responsible for frequency management, installation, operation, and
               maintenance of the MMST communications system

              Coordinates communications with other appropriate entities

              Is responsible for the accountability of all components of the MMST
               communications system

              Maintains appropriate records and reports

              Performs additional tasks or duties as assigned during a mission


   (3) Operational Checklist

      (a) Prior to activation:

      Ensures personal ''GO'' kit is available and prepared for deployment

      Ensures all communications equipment is fully operational


      (b) Upon activation:

      Monitors disaster-related information from local sources

      Issues communications radio equipment to MMST personnel and:

                Identifies the assigned frequency(ies)
                Briefs members on accountability, use, and care



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                                                                                  City of Seattle
                                                                 Seattle Fire Department (SFD)
                                                    _Metropolitan Medical Strike Team (MMST )

               Ensures personnel are aware of the prohibition of the use of radios
                where indicated


      (c) At mobilization site:

      Advises Communications Group Supervisor of arrival

      Assembles for a MMST briefing from the TFL

      Assists with the movement and loading of equipment

      Affixes appropriate functional identifier

      Brings personal ''GO'' kit


      (d) In transit:

           Reviews the latest disaster-related information as available

           Reviews information pertinent to position description, operational checklist,
           operational procedures, and safety procedures

           Takes advantage of available travel time for rest prior to arrival

           Discusses the formulation of the communications plan with the
           Communications Group Supervisor


      (e) On-site ope rations:

           Ensures personal physical readiness through proper nutrition, water intake,
           rest, and stress control techniques

           Provides for communications equipment security and protection from the
           elements. Assists with the unloading, sorting and setup of the
           communications equipment cache

           Assists in the establishment of communications with Local Incident
           Command Structure

           Assist in determining on-site operating frequencies. Assist in the
           development of the communications plan




11/05/10                                                                                  3-136
                                                                                  City of Seattle
                                                                 Seattle Fire Department (SFD)
                                                    _Metropolitan Medical Strike Team (MMST )

           Determines medivac communications capabilities. Identifies other
           communications systems that could enhance operations.

           Receives initial briefing of tactical assignment from the TFL or designee
           including:

              Incident situation report
              MMST objectives
              Tactical assignments
              MMST support layout and requirements (Base of Operations)
              Review of emergency signaling and evacuation procedures
              Review of medical treatment and evacuation procedures
              Review of the process for ordering supplies and equipment
              Possible reassignment to Plans Section during an incident

           Assist in setting- up communications system for MMST operations

           Assist in maintaining Communication Log.

           Assist in the tracking the location of MMST personnel.

           Carries out tactical assignments as directed.

           Anticipates requirements and evaluates the communications system
           effectiveness. Modifies to meet changing operational needs.

           Monitors MMST communications for compliance with established procedures

           Monitors electrical and battery supply status and provides replacements as
           necessary. Inventories and reorders as needed

           Ensures physical readiness through proper nutrition, water intake, rest, and
           stress control techniques

           Reports any signs or symptoms of personal critical incident stress in
           coworkers and advises the Team Medical Section Chief

           Keeps the Communications Group Supervisor apprised of any tactical
           accomplishments or conflicts, supplies deficiencies, or equipment
           malfunctions

           Briefs shift replacement fully on all ongoing operations when relieved at work
           cycle rotations

           Participates in the MMST daily briefings


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                                                                                  City of Seattle
                                                                 Seattle Fire Department (SFD)
                                                    _Metropolitan Medical Strike Team (MMST )



(f) Demobilization:

           Assembles for a Team briefing on the mission status and
           reassignment/demobilization determinations

           Ensures that assigned tools and equipment are inventoried, returned to the
           cache, and prepared for movement. Ensures that all communications
           equipment is properly cleaned, decontaminated, calibrated, and repackaged
           for transport

           Assists with the packaging, movement, and loading of the communications
           equipment cache

           Notifies the Logistics Specialist of the losses or potential maintenance
           requirements of any tools and equipment

           Assists with the breakdown and policing of the MMST operational area


      (g) Post-incident:

           Reports any ill or unusual feelings or sicknesses that may be attrib utable to
           exposure at the incident

           Submits reports to the Communications Group Supervisor for inclusion in the
           After-Action Report.

           Ensures the return of all items issued to Communications Specialist during the
           mobilization phase. Ensures that all issued radios are returned to the cache

           Ensures communication equipment is ready for next deployment

           Upon return, participates in the MMST mission critique and CISM debriefing

           Restores personal ―GO‖ kit to deployment status

           Section members will make contact with their employing agency to inform them
           of the termination of their participation in MMST activation and follow the time
           and attendance reporting requirements of their home jurisdiction.




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                                                                                                                                                             City of Seattle
                                                                                                                                            Seattle Fire Department (SFD)
                                                                                                                               _Metropolitan Medical Strike Team (MMST )



                                                        Seattle Fire Department

                                METRO MEDICAL STRIKE TEAM      (Proposed 62 Person Team)




                                                                       TFL

                                                    Law Enforcement                    Safety
                                   Security             Liaison                        Officer


                                                        Medical                       Hospital
                                                        Director                      Liaison



                    OPERATIONS                        PLANS                                      LOGISTICS                        TEAM-MEDICAL
                     SECTION                         SECTION                                      SECTION                           SECTION
                       CHIEF                          CHIEF                                        CHIEF                             CHIEF


       Field-Medical (FM)     Field-HazMat (FH)        Plans                 Communications                   Logistics                 TM - Unit 1
             Group                  Group             Group                      Group                         Group                   1 Unit Leader
           Supervisor             Supervisor         Supervisor                Supervisor                    Supervisor                 1 Specialist

                                                                                                                                        TM - Unit 2
               FM - Unit 1           FH - Unit 1         Intelligence                 Comm Unit                 Log. Unit 1            1 Unit Leader
             1 Unit Leader         1 Unit Leader       Info - Specialist              1 Specialist             1 Unit Leader            1 Specialist
              5 Specialists         5 Specialists    (Law Enforcement)                                          1 Specialist

               FM - Unit 2           FH - Unit 2          HazMat                                                Log. Unit 2
             1 Unit Leader         1 Unit Leader      Info - Specialist                                        1 Unit Leader
              5 Specialists         5 Specialists        (Chemist)                                              1 Specialist

                                     FH - Unit 3          Medical
                                   1 Unit Leader      Info - Specialist
                                    5 Specialists      (Toxicologist)

                                     FH - Unit 4
                                   1 Unit Leader
                                    5 Specialists




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                                                                                  City of Seattle
                                                                 Seattle Fire Department (SFD)
                                                    _Metropolitan Medical Strike Team (MMST )



V. TEAM MEDICAL SECTION

   A) Team Medical Section Chief

   (1) Introduction

   The Team Medical Section Chief is responsible for directly managing and
        supervising the Team Medical function of the MMST. The Team Medical
        Section Chief works in coordination with the Medical Director to implement
        established medical protocols and procedures. He/she reports directly to the
        Task Force Leader.


   (2) The Team Medical Section Chief performs the following duties:

             Is responsible for the development and implementation of the Team
            Medical Plan

              Coordinates medical activities of MMST members

               Directly supervises the Team Medical Specialists and ensures adherence
            to all safety procedures

              Is responsible for the determination of medical logistics needs

               Receives briefings and situation reports and ensures that all medical
            personnel are kept informed of status changes

              Provides situation reports, maintains records, reports, and evaluations

               Directs medical care delivery to MMST personnel and incident victims by
            established protocols

               Ensures continuous medical performance, evaluation, and coordination
            with all available local medical entities

              Performs additional tasks and duties as assigned during a mission

   (3) Operational Checklist

      (a)       Prior to activation:

            Ensures ''GO'' kit is available and ready for deployment



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                                                                                  City of Seattle
                                                                 Seattle Fire Department (SFD)
                                                    _Metropolitan Medical Strike Team (MMST )



      (b)       Upon activation:

            Receives notification and location of mobilization site

            Monitors disaster-related information from local sources


      (c)      At mobilization site:

            Advises the TFL of arrival

            Receives TFL briefing

            Ensures all Team Medical Specialists have arrived

            Briefs assigned personnel

            Reviews pertinent equipment cache readiness status

            Procures the medications as specified on the medical cache list, as needed

            Initiates and maintains the organizational structure and integrity of Tea m
            Medical throughout all phases of the mission

            Meets with assigned personnel to determine if they are prepared, self-
            sufficient, and adequately equipped to perform their assignments

            Ensures that assigned personnel are adequately briefed on and understand that
            treatment of MMST members is their highest priority

            Assigns personnel to assist with the movement and loading of the Team
            Medical equipment cache

            Ensures medical specialists complete the National Disaster Medical System
            (NDMS) liability coverage form, as needed

      Affixes appropriate functional identifier

      Brings personal ''GO'' kit

            Briefs MMST personnel on the medical support procedures and resources
            available




11/05/10                                                                                  3-141
                                                                                  City of Seattle
                                                                 Seattle Fire Department (SFD)
                                                    _Metropolitan Medical Strike Team (MMST )

            Assigns responsibilities and supervises personnel on the off- loading and
            security of Team Medical equipment in conjunction with the Logistics Section
            Chief

            Assesses and determines the availability of resources in conjunction with the
            Logistics Section Chief

            Meets with the Medical Director and receives:

               -   Briefing, when available
               -   Introduction to local personnel with whom the MMST will be working
               -   Operational Protocols

            Asembles assigned personnel for briefing from TFL

            Identifies medical supplies and equipment that should receive logistical
            priority


      (d)       In transit:

            Reviews the latest disaster-related information

            Ensures that all personnel review their position description, operations
            checklist, operational procedures, and safety procedures

            Discusses and coordinates anticipated logistical requirements with the
            Logistics Section Chief

            Ensures that all assigned personnel take advantage of available travel time for
            rest period prior to arrival


      (e)       On-site operations:

            Assigns personnel to assist the Logistics Specialist with unloading, sorting,
            and setup of the equipment cache for medical operations activities

            Assigns personnel to complete pre-entry medical surveillance

            Assigns personnel to become part of decon Team, if needed

            Receives initial briefing of tactical assignment from the Task Force Leader:

               -   The incident situation report



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                                                                                City of Seattle
                                                               Seattle Fire Department (SFD)
                                                  _Metropolitan Medical Strike Team (MMST )

              -   MMST objectives
              -   Tactical assignment
              -   MMST support layout/requirement
              -   Reporting requirements for situation report
              -   Designation of the initial communication plan, frequencies, and radio
                  designations


      Assures personnel are properly using appropriate PPE and respiratory protection

      Reviews emergency warning signaling and evacuation procedures to be utilized

      Reviews medical treatment/evacuation procedures to be employed

      Reviews process for reordering supplies and equipment

      Reviews local medical capabilities and transport procedures initiated

           Begins overall assessment process to determine the functional
           requirements/immediate needs, rest, and rotation periods for personnel,
           adequacy of equipment and support facilities

           Performs needs assessment/locates available resources

              -   Determines patient hand-off procedures
              -   Medical resupply

           Conveys information to the TFL of need for additional resources/special
           medical capabilities. Information should be passed on through the chain of
           command to Local, State, and EMS officials.

           Evaluates ongoing Team Medical operations for effectiveness and modifies as
           appropriate. This should include appropriateness and effectiveness of tactics,
           assessment of equipment shortages and needs, assessment of antidote needs/
           shortages, and patient transport issues.

           Ensures personal physical readiness through proper nutrition, water intake,
           rest, and stress control techniques

           Assures the health and welfare needs of team personnel, including:

              -   The need to drink fluids, eat food, and take rest
              -   Assessment of prolonged fatigue in personnel
              -   Assessment of signs of Critical Incident Stress syndrome in personnel



11/05/10                                                                                3-143
                                                                                 City of Seattle
                                                                Seattle Fire Department (SFD)
                                                   _Metropolitan Medical Strike Team (MMST )

           Coordinates with the Operations Section Chief regarding decontamination
           procedures

           Works with the Operations Section Chief to ensure the integration of medical
           personnel in rescue operations for purposes of medical assessment,
           decontamination, and stabilization of victims prior to pass-off.

           Coordinates the management and treatment of the injury of any MMST
           member, medical evacuation to local care or return home, patient care form,
           Federal or Local form/report and communication to ICP, local command post,
           and sponsoring organization.

           Coordinates with the Law Enforcement Liaison on issues regarding the death
           of an MMST member, in conjunction with the MMST Safety Officer:

              -   Security of personal effects
              -   Initiates proper documentation
              -   Communication to TFL, local ICP, and sponsoring organization
              -   Transfer of remains to medical examiners office
              -   Coordinates with local command post, USPHS, and funeral home

           Assesses the impact of continued MMST operations

           Monitors on-site coordination with other functions within the MMST/other
           rescue team/local officials

           Provides direct medical care as appropriate to injured MMST personnel. This
           includes intervention of Critical Incident and Stress Management (CISM) for
           MMST personnel, if necessary

           Provides guidance to MMST personnel on self-care matters

           Assures that proper safety practices and procedures are understood and
           monitored for compliance

           Evaluates the capacity of assigned resources to complete the assignment/order
           additional resources, if needed

           Resolves any coordination, communication, or personnel problems with the
           appropriate section chief

           Makes periodic progress reports to the TFL of accomplishments/conflicts
           identified at the completion of assignment and the availability of resources




11/05/10                                                                                 3-144
                                                                                 City of Seattle
                                                                Seattle Fire Department (SFD)
                                                   _Metropolitan Medical Strike Team (MMST )

            Updates shift replacement fully on ongoing operations when relieved at work
            cycle rotations

            Assures completion of all patient evaluations/care forms and Controlled Drug
            Accountability forms

            Participates in MMST strategy sessions with the TFL and other appropriate
            MMST members

            Coordinates management of deceased victims with Law Enforcement Liaison
            and the primary law enforcement agency

            Briefs shift replacement fully on all ongoing operations when being relieved
            at work cycle rotations


      (f)       Demobilization:

            Briefs team personnel on mission status and reassignment/ demobilization
            directions

            Coordinates the necessary follow-up and care for any MMST member treated
            by the medical personnel

            Ensures all assigned pharmaceuticals and equipment are inventoried, returned to
            the cache, and prepared for movement

            Records any operational losses and potential maintenance requirements of tools
            and equipment

            Assigns personnel to assist with the breakdown and policing of the MMST
            Base of Operations (BOO)

            Assigns personnel to assist with packaging, movement, and loading of the
            medical equipment cache

            Receives reports from Team Medical Specialists and submits final Team
            Medical report to Plans Section Chief for inclusion in the After-Action Report


      (g) Post-incident:

            Reports any ill or unusual feelings or sicknesses that may be attributable to
            exposure at the incident



11/05/10                                                                                 3-145
                                                                                     City of Seattle
                                                                    Seattle Fire Department (SFD)
                                                       _Metropolitan Medical Strike Team (MMST )

           Ensures the return of all items issued to Team Medical personnel during the
           mobilization phase

           Coordinates participation of Team Medical personnel on MMST mission critique
           and CISM session

           Restores ‗‗GO‘‘ kit to deployment status.

           Section member will make contact with their employing agency to inform them
           of the termination of their participation in MMST activation and follow the time
           and attendance reporting requirements of their home jurisdiction.




11/05/10                                                                                     3-146
                                                                                   City of Seattle
                                                                  Seattle Fire Department (SFD)
                                                     _Metropolitan Medical Strike Team (MMST )



B) Team Medical Specialist

   (1) Introduction

           The Team Medical Specialists is a Firefighter/Paramedic and will be responsible
           for performing medical care at an incident operation. All Medical Specialists
           report to the Operations Section Chief for assignment to Field Medical or Team
           Medical Group.


   (2) The Medical Specialist is responsible for the following duties:

              The general health and medical care for all MMST personnel and incident
               victims

              The implementation of the medical action plan

              Providing medical care in accordance with MMST treatment protocols

              All issued equipment

              Will be prepared to accept the assignment of unit leader

              Additional task and duties as assigned


   (3) Operational Checklist

      (a) Prior to activation:

           Ensures personal ―GO‖ kit is available and ready for deployment


      (b) Upon activation:

           Receives notification and instructions for arrival at the mobilization site

           Monitors disaster-related information from local sources

           Reports to the assigned mobilization point




11/05/10                                                                                   3-147
                                                                                     City of Seattle
                                                                    Seattle Fire Department (SFD)
                                                       _Metropolitan Medical Strike Team (MMST )

      (c) At mobilization site:

           Affixes appropriate functional identifier

           Brings personal ―GO‖ kit

           Notifies the Operations Section Chief of arrival and receives assignment

           Ensures all section personnel have signed U.S. Public Health Service National
           Disaster Medical System liability coverage form, if appropriate

           Assists with the transfer and loading of MMST medical equipment, as necessary

           Assembles for MMST briefing from the TFL

           Coordinates the security and accountability of controlled drugs with the Logistics
           Section Chief and Team Medical Section Chief


      (d) In transit:

           Reviews information pertinent to their position description, operations, checklist,
           operational procedures and safety procedures

           Reviews latest disaster-related information available

           Take advantage of available time to rest


      (e) On-site operations:

           Performs pre- and post-entry medical surveillance on MMST personnel donning
           PPE

           Assists personnel donning PPE

           Ensures personal physical readiness through proper nutrition, water intake, rest,
           and stress control techniques

           The treatment priorities for medical personnel (including field members) are:

              First, MMST personnel
              Second, local response personnel who become ill or injured
              Third, victims directly encountered by the MMST
              Fourth, other injured/affected persons as practical


11/05/10                                                                                     3-148
                                                                                  City of Seattle
                                                                 Seattle Fire Department (SFD)
                                                    _Metropolitan Medical Strike Team (MMST )




           Completes appropriate medical records

           Accompanies injured MMST personnel to the hospital when directed by the TFL

           Briefs shift replacement fully on all ongoing operations when being relieved at
           work cycle rotations


      (f) Demobilization:

           Advises Section Leader when assignments are completed

           Assists with the breakdown of their assigned section

           Assures collection and return of equipment and supplies to Logistics Section


      (g) Post-incident:

           Reports any ill or unusual feelings or sicknesses that may be attributable to
           exposure at the incident

           Participates in MMST mission critique and CISM debriefing

           Completes reports and forwards to the Team Medical Section Chief for inclusion
           in the After-Action Report

           Assists with assuring cache is ready for next deployment

           Restores ―GO‖ kit to deployment status

           Section members will make contact with their employing agency to inform them
           of the termination of their participation in MMST activation and follow the time
           and attendance reporting requirements of their home jurisdiction.




11/05/10                                                                                  3-149
                                                                                    City of Seattle
                                                                   Seattle Fire Department (SFD)
                                                       Metropolitan Medical Strike Team (MMST)
                                        APPENDIX A

                       METROPOLITAN MEDICAL S TRIKE TEAM
                  RECOMMENDED PHYS ICAL EXAMINATION COMPONENTS



I.           ADMINISTRATIVE

             A.   The MMST member‘s Department will be responsible for ensuring that
                  MMST team members have successfully completed the required
                  Metropolitan Medical Strike Team (MMST) physical examination on an
                  annual basis, or a separate examination will be arranged.

                  1.     The examination requirement may be met by personnel having the
                         examination completed through their department/agency, or a
                         separate examination will be arranged by the PMT using outside
                         resources.

                  2.     If an outside resource is utilized, the cost of the examination will
                         be separately addressed.

             B.   A physical examination file will be maintained for each member.

             C.   Designated sections of each MMST member‘s file may be reproduced and
                  kept in a secure location in the medical cache to be used by emergency care
                  personnel in the event that a team member becomes ill or injured during a
                  deployment or training exercise.

             D.   All medical information on each MMST member will be kept confidential
                  and not released without the written permission of the team member.

             E.   The MMST Medical Director will annually review the files of all team
                  members to determine their team eligibility for the coming year.

             F.   It will be the responsibility of all team members to ensure their latest
                  physical examination results are submitted.

             G.   Team members found not meeting current physical standards will not be
                  allowed to participate in a deployment or training exercise until such time
                  as they meet the standards.




11/ 05/ 10                                                                                   3-A-1
                                                                                               City of Seattle
                                                                              Seattle Fire Department (SFD)
                                                                  Metropolitan Medical Strike Team (MMST)
             H.       All team members are expected to keep the following immunizations
                      current:

                      1.       Tetanus
                      2.       Diphtheria
                      3.       Hepatitis
                      4.       Measles, mumps, rubella (MMR)
                      5.       Polio

             I.       Verification of current immunizations must be submitted as part of each
                      annual physical examination report.



II.          EXAMINATION COMPONENTS

             A.       The annual physical examination components for all MMST members will
                      include the following:

                      1.       Occupation-based history
                      2.       Complete physical examination including thorough assessment of:

                                   Integument
                                   Cardiovascular system
                                   Respiratory system
                                   Musculoskeletal system
                                   Central nervous system
                                   Psychological status

                      3.       All team members must complete the Seattle Fire Department‘s
                               Hazardous Materials physical examination, or equivalent.

             B.       The examination results will be recorded by the examining physician on
                      the Seattle Fire Department or MMST physical examination record sheet.

             C.       In the event of a deployment, appropriate post incident examinations and follow -
                  up procedures will be imp lemented.




11/ 05/ 10                                                                                                3-A-2
                                                                                              City of Seattle
                                                                              Seattle Fire Department (SFD)
                                                                 Metropolitan Medical Strike Team (MMST)
                                                     APPENDIX B

                           METROPOLITAN MEDICAL STRIKE TEAM
                               INCIDENT EXPOSURE REPORT


DEMOGRAPHIC DATA

1) Last Name:                                                                               2) First Name:

3) Agency:                                     4) SSN:           -      -               5) Station:                         6)
Shift :

7) Incident Date:                              8) Incident No.:                                        9) Assignment:

SPECIFIC INCIDENT DATA

Incident Type (Circle one)
10) Poisonous Gas Release                             11) Et iologic Release                         12) Rad iation Incident

Level of Protection Worn (Circle one)
13) FF Ensemble            14) FF Ensemble/SCBA                      15) Splash Gear
16) Splash/SCBA 17) Splash/APR
18) Encap. Suit            19) Other:

Activity Done (Circle one)
20) Entry-Recon        21) Entry -Rescue          22) Decon           23) Patient treat ment           24) Other:

Exposure Data (Check one)
25) Smo ke/FUM E/ Vapor Condition:                    __None                  __Light                         __Heavy
26) Type of Personal Exposure: __Inhaled __Ingested __Skin/Mucous Membrane Contact __Injection
__None
27) Exposure Risk:                      __ Direct Contact        __ Exposure        __ Near Exposure            __ None

Exposure Durat ion:       Place one of the fo llo wing exposure durations in the appropriate box in Table 1 for
                          each chemical or substance the Strike Team was exposed to.
                    A) <15 min.               B) 15-30 min.          C) 30-60 min.             D) 1-2 hr.           E) >2 hr.
Table 1.
                                                                     Light/
                                                 Vapor/              Heavy      Light       Solid/    Combustible                  Measured
 Write in the chemical or substance present       Gas     Dust        Mist      Mist       Powder       Product       Radiation    Quantity
28)
29)
30)
31)
32)




11/05/10                                                                                                                   3-B-1
                                                                                         City of Seattle
                                                                         Seattle Fire Department (SFD)
                                                            Metropolitan Medical Strike Team (MMST)
Scene Sy mptoms (Check Responses)

                                            At      After                                                            At      After
                                          Incident Incident                                                        Incident Incident

33)   Eye Irritation/Burning                __          __           39)       Headache                              __       __
34)   Coughing                              __          __           40)       Skin Irritation/Rash                  __       __
35)   Shortness of Breath                   __          __           41)       Throat Irritation                     __       __
36)   Respiratory Irritation                __          __           42)       C/P __                                __
37)   Abdominal Pain/Bleeding               __          __           43)       Other:
38)   Light-headedness/Dizziness            __          __           44)       Other:

Scene Medical Surveillance (Circle one)
                                                                                                                     Final Pre-entry
45) Pre -entry Assessment Done     __No       __ Yes            BP / P                R          T           EKG

                                                                                                                    Final Post-entry
                                                                BP / P                R         T            EKG

46) Decontamination Performed      __No       __ Yes
47) On-scene Treat ment            __No       __ Yes        __ Oral Flu ids                    __O2                __IV
                                                            __ Other:                                    ,
48) Transported to ED              __No       __ Yes        __ Hospital:

Post-Incident Analysis by Department Surveillance Officer

49) Date Form Reviewed:
50) M D Physical Exam Needed?                    __No        __ Yes, by Dr.
51) Lab Needed?       __No    __ Yes                                 Date:        /       /   Results:
                                                                     Date:        /       /   Results:
                                                                     Date:        /       /   Results:
                                                                     Date:        /       /   Results:

52) X-rays Needed?        __No     __ Yes                            Date:        /       /   Results:
                                                                     Date:        /       /   Results:
                                                                     Date:        /       /   Results:
                                                                     Date:        /       /   Results:
53) Date Results Discussed With Individual:             /        /         .
54) Final Disposition:    __ Full Duty       __ Light Duty           __ Injury Leave             __ Other:


Signature:                                                                         Date:




11/05/10                                                                                                            3-B-2
                                                                              City of Seattle
                                                             Seattle Fire Department (SFD)
                                                 Metropolitan Medical Strike Team (MMST)
                                            APPENDIX C

                       METROPOLITAN MEDICAL STRIKE TEAM
                        PRE-/POST-ENTRY MONITORING FORM

  Name:                                  Date:               Incident #:               Assignment #:


  Exposure Ri sk:    (A) Direct Cont act          (B) Exposure       (C) Indirect Exposure           (D)
  None
  Work Activity:           (A) Hot Zone     (B) Decon        (C) Medical Care         (D) Other:

                                                       ENTRY #1            ENTRY #2            ENTRY #3
      EXAMINATION COMPONENTS/
         EXCLUSION CRITERI A                     Pre     Post       Pre      Post        Pre         Post
BP:      Systolic      100-150 mmHg
         Diastolic     < 90 mmHg
Pulse:                 > 50'
                       < 110'
Respirations:          > 12'
                       < 20'
Temperature:           > 97
                       < 100
EKG Interpretation
Weight
Mental Status Examination Score
Skin Abnormalities (ra sh, wound)
              Yes ___         No ___
Lung Abnormalities (rales, wheezes)
            Yes ___          No ___
Abdomen Problems (pain, N/V,
diarrhea)
             Yes ___         No ___
Eye Abnormalities
              Yes ___           No ___
Musculoskeletal Abnormalities
              Yes ___       No ___
Medication Exclusion
              Yes ___           No ___
Examination Time
Final Status           1    2    3   4
Evaluator




  11/05/10                                                                                         3-C-1
                                                                                      City of Seattle
                                                                     Seattle Fire Department (SFD)
                                                         Metropolitan Medical Strike Team (MMST)
                                      METROPOLITAN MEDICAL STRIKE TEAM
                                      PRE-/POST-ENTRY MONITORING FORM


Prior to any physical functions of MMST members involved in entry evolutions or decontamination activities,
a pre-incident entry physical examination must be completed. These examinations will be performed by
designated field operations personnel.

Due to the physical and mental demands of hazardous materials responses, it is imperative that the pre -
incident survey is completed quickly and effectively. The results of this survey will be used to determine the
suitability of team personnel to perform in personal protective clothing (PPE).

In order to adequately track each member's condition, each section of the examination has been developed
to place the hazardous materials responder into one of four possible categories as listed below:

Status 1 -      No condition exists that prevents the responder from performing any task on a hazardous
                material incident.

Status 2 -      A minor condition exists that will need to be re-evaluated in 15 to 20 minutes. During this time
                period, the responder will stay at rest and have no assignments placed on him/her. If after 15
                to 20 minutes this evaluation does not change or worsens, the responder will be placed into
                Status 3.

Status 3 -      A condition is present that will not allow a responder to wear PPE or perform any demanding
                or stressful work. This person will be re-evaluated in 15 to 20 minutes to be assured that the
                condition does not worsen. If after 15 to 20 minutes the condition does not change or
                worsens, the responder will be placed into Status 4.

Status 4 -      A serious condition exists that excludes the responder from any physical functions. The
                examining personnel should consider whether this person should be transported to the
                hospital. If questions exist, the Team Medical Section Chief should be consulted.

PHYSICAL SURVEY COMPONENTS/EXCLUSION CRITERIA

Blood Pressure: Systolic          100 - 150                                             Status 1
                                  < 100 (if not normal for the individual)              Status 2
                                  > 150                                                 Status 3

                    Diastolic     < 90                                       Status 1
                                  95 - 100                                              Status 2
                                  > 100                                                 Status 3

Pulse:              50 - 110                                                            Status 1
                    < 50 (if not normal for the individual)                             Status 2
                    >110                                                                Status 3

Respirations:       12 - 20                                                             Status 1
                    < 12                                                     Status 2
                    > 20                                                     Status 3

Temperature:        96 - 100                                                            Status 1
                    < 96                                                     Status 2
                    > 100                                                               Status 3

Weight:         To be recorded while responder is in shorts or coveralls. (Allow 2 pounds for coveralls.)




11/05/10                                                                                                    3-C-2
                                                                                    City of Seattle
                                                                   Seattle Fire Department (SFD)
                                                       Metropolitan Medical Strike Team (MMST)
Skin:        Check appearance for any rashes or abnormalities. Document size and location of rashes. It
             will be at the discretion of the Team Medical Section Chief to determine when the rash,
             abnormality, etc., will allow the member to perform certain tasks. Personnel with open or
             weeping wounds should generally not be working in situations where skin absorption of a toxin
             is possible.

Eyes:        Check pupils for size and reactivity. Check eyes for appropriate movement. Comparisons
             should be made with the baseline examination to determine abnormalities. If gross differences
             exist, refer to physician. Status 4.

Lungs:       Listen for wheezes, rales, or bilateral equal sounds. If wheezes, rales, or unequal breathing
             sounds exist, the responder will be placed in Status 2 or Status 3, per the discretion of the
             Team Medical Section Chief.

Heart:       An y chest pain. Cardiac arrhythmia (with the exception of sinus arrhythmia). Status 3.

Abdomen:     An y abdominal pain/cramping                        Status 3
             Nausea or vomiting                                  Status 3
             Diarrhea                                            Status 3

Mental Status Examination (see attached worksheets):             Score 20 - 22               Status 1
                                                                 Score < 20                  Status 2

Musculoskeletal:           At the discretion of the Team Medical Section Chief, any recent or ongoing injury
                           may be placed into Status 2.

Recent Medical History:    If a member of the MMST has had a condition that required that person to be off
                           work within 48 hours of the response, a Status 2 is indicated.

Current Medications:       If a member is taking one of the following medications, that person will not be
                           allowed to wear Level A or B clothing:

                           -- Phenothiazines       -- Bronchodilator      -- Narcotics      -- Antihistamine
                           -- Decongestants        -- Antibiotics for respiratory, ear, or GI problems

Other:   If a member is under current treatment for middle ear, respiratory, genito -urinary, or gastrointestinal
         (GI) problems, that member should not be allowed access to SCBA or encapsulated clothing. Any
         other components or findings not listed above will be categorized at the discretion of the Team
         Medical Section Chief.

         If a member of the MMST has a condition that requires wearing a cast, brace, etc., that team
         member shall not participate in a frontline position (hot or warm zone) unless cleared by a
         physician. Consideration should be given to that member’s working in a command function.




11/05/10                                                                                                 3-C-3
                                                                        City of Seattle
                                                       Seattle Fire Department (SFD)
                                           Metropolitan Medical Strike Team (MMST)
                       METROPOLITAN MEDICAL STRIKE TEAM
                        MENTAL STATUS EVALUATION FORM


 MAXIMUM           SCORE
   SCORE         PRE / POST

                                                                 ORIENTATION

       3               /      Oriented to person, place, and time?

                                                                REGISTRATION

       3               /      Name three objects:           One second to say each. Then ask the
                              Truck                         patient all three after you have said them.
                              Radio                    Give one point for each correct answer.
                              Suit                     Then repeat them until he/she learns
                                                       all three. Count trials and record number.

       5               /      Count serial 7s. One point for each correct answer. Stop after five
                              answers. Alternatively, spell ‘‘world’’ backwards.

                                                                    RECALL

       3               /      Ask for the three objects repeated above. Give one point for each
                              correct answer.

                                                                  LANGUAGE

       4               /      Name a pencil and watch. (2 points)
                              Repeat the following: ‘‘No ifs, ands, or buts.’’ (1 point)
                              Write your signature. (1 point)



Pre-signature:                                Post-signature:

ASSESSMENT OF LEVEL OF CONSCIOUS NESS THROUGH THIS MENTAL EXAMINATION
PROCESS

       4               /      Alert (1 point)
                       /      Drowsy (1 point)
                       /      Stupor (1 point)
                       /      Coma (1 point)

       22              /      TOTAL SCORE FOR THIS E XA MINA TION

Additional Comments:




11/05/10                                                                                   3-C-4
                                                                                     City of Seattle
                                                                    Seattle Fire Department (SFD)
                                                        Metropolitan Medical Strike Team (MMST)
                                         APPENDIX D

                           METROPOLITAN MEDICAL S TRIKE TEAM
                                  MEDIA PROCEDUR ES



I.                 INTRODUCTION

              The activation and mobilization of an MMST will usually occur when a
               calamitous, large-scale NBC event has occurred that overwhelms the
               capabilities of local and State resources.

              As proven in past occurrences, events of this type will result in significant
               media attention.
              The general media policy for the MMST Response System is to establish and
               maintain an active relationship with all facets of the media during periods of
               normalcy and disaster.

              Primary elements of the Response Plan include various Federal agencies,
               State and Local governments, and other affiliated organizations.

              These elements must develop and disseminate coordinated public informa tion
               to the media and public jointly and independently.
              The MMST Media Procedures outline standard procedures for:

                Activities and preparation for media-related issues prior to a mobilization.

                Media interaction for during all phases of a mission assignment.

                Identification of public awareness materials to support the preparedness
                 and response activities of the MMST.

II.                INFORMATION FLOW

              Information flow related to MMST disaster response activities will be
               managed and coordinated by the sponsoring jurisdiction and the TFL or their
               designee.




11/ 05/ 10                                                                                    3-D-1
                                                                                                             City of Seattle
                                                                                            Seattle Fire Department (SFD)
                                                                                Metropolitan Medical Strike Team (MMST)
              The MMST Plans Section Chief will coordinate all information to be released
               to the public with the TFL, Medical Director and the local PIO.

III.         SYSTEM IMPLEMENTATION
             The Plans Section Chief will act as the PIO for the MMST and will be responsible
             to:

              Establish an ongoing process for coordination with the local USPHS Office of
               Public Affairs Representative.

              Obtain current mission-specific information about the event from the TFL.

              Respond to requests from other media representatives.

                Coordinate media notification of MMST activation, with the local PIO.

              Coordinate with public affairs officials at the designated Point of Departure
               identifying expected media interest (interview, media access restrictions, etc.).

              Participate in the TFL‘s initial briefing at the Point of Assembly or Point of
               Departure, reviewing appropriate media guidelines (i.e., Do‘s and Don‘ts,
               information flow, interviews, etc.).

              Coordinate all media activities and interviews.
              Coordinate family liaison procedures to update MMST members‘ families on
               a scheduled basis if needed.

              Provide assistance and guidance to family members should they be contacted
               and/or interviewed during the course of a mission.


IV.                   MEDIA-RELATED INFORMATION FLOW

              Information flow to the press and media for disaster response activities will be
               managed and coordinated by the local jurisdiction and/or the appropriate
               Federal authority.

              The Plans Section Chief will serve as the MMST PIO when needed.
              The TFL will assure that MMST specific information is relayed to the local
               PIO.
V.                ON ASSIGNMENT

              All MMST personnel will comply with the following media guidelines while
               on mission assignment:

                  Inquiries made to the MMST should be directed to the TFL.



11/ 05/ 10                                                                                                            3-D-2
                                                                                     City of Seattle
                                                                    Seattle Fire Department (SFD)
                                                        Metropolitan Medical Strike Team (MMST)
              At times it may not be feasible or practical to defer media inquiries up the
               chain of command to the local jurisdiction. Accurate information should be
               provided within the confines of one‘s job knowledge and responsibility.

              The local jurisdiction‘s ICP/PIO may request TF personnel to assist in media
               interviews during the course of operations.

VI.                DEMOBILIZATION AND RETURN HOME
A.           When the MMST is demobilized:

              The MMST PIO will continue to coordinate public information efforts
               regarding the MMST.

              The MMST PIO will issue press releases, conduct briefings, or provide other
               appropriate follow-up public information material detailing activities and
               results of the TF response effort.

B.           When the MMST is demobilized, the PIO from the sponsoring organization
             should assist with:

              Coordinating MMST arrival schedule, media attendance, and coordination.

              Coordinating all media activities during MMST return, including interviews,
               photo opportunities, etc.

              Scheduling and conducting news conferences with selected MMST personnel
               for the media 1 or 2 days after their return (if appropriate).
              Collecting appropriate news clippings and video footage of MMST
               accomplishments.
              Conducting a review/critique of the overall media management and
               coordination; documenting strong and weak points; developing lessons
               learned and incorporating into the sponsoring organization‘s procedures for
               future improvement.
              Submitting recommendations and concerns to TFL.


VII.         INTERVIEWING ‘‘DO’S’’ AND ‘‘DON’TS’’
A.           ‗‗DO‘S‘‘

              Ask the reporter‘s name. Then use it in your response.

              Use your full name. Nicknames are not appropriate.

              Choose the site (if possible). Make sure you are comfortable with the location
               of the interview. Consider what is in the background.

11/ 05/ 10                                                                                    3-D-3
                                                                                                          City of Seattle
                                                                                         Seattle Fire Department (SFD)
                                                                             Metropolitan Medical Strike Team (MMST)

              Choose the time (if possible). If you would be more comfortable waiting
               another 5 minutes, ask the reporter if that‘s okay.
                Be calm. Your demeanor and apparent control of the situation are very important in establishing the tempo of evolving
                 events.

              Tell the truth.

              Be cooperative. There is an answer to most questions, and if you don‘t know
               it now, let them know you will work diligently to determine the facts needed.
              Be professional. Don‘t let your personal feelings abut the media, or this
               reporter in general, affect your response.

              Be patient. If the same question is asked again, repeat your answer without
               irritation.

              Take your time. If you make a mistake, indicate that you would like to start
               over with your response.

              Use wrap-around sentences. This means repeating the question with your
               answer for a complete ‗‗sound bite.‘‘

B.           ‗‗DON‘TS‘‘
              Say ‗‗no comment.‘‘

              Give your personal opinion. Stick to the facts.

              Go off the record. Anything you say can/will be used.

              Lie.

              Bluff. The truth will come out.
              Be defensive. The media/audience recognize a defensive attitude and tend to
               believe you‘re hiding something.

              Be afraid. Fear is debilitating and is not a characteristic you want to portray.
              Be evasive. Be up front on what you know about the situation and what you
               plan to do to mitigate the incident.

              Use jargon. The public is not familiar with much of the language used in the
               MMST field.
                Confront.

              Try to talk and command an incident at the same time.

              Wear sunglasses.


11/ 05/ 10                                                                                                                    3-D-4
                                                                            City of Seattle
                                                           Seattle Fire Department (SFD)
                                               Metropolitan Medical Strike Team (MMST)
              Smoke.

              Promise results or speculate.

              Respond to rumors.




11/ 05/ 10                                                                           3-D-5
                                                                                              City of Seattle
                                                                             Seattle Fire Department (SFD)
                                                                 Metropolitan Medical Strike Team (MMST)
                                                APPENDIX E

                               METROPOLITAN MEDICAL S TRIKE TEAM
                              PATIENT DECONTAMINATION PROCEDURE



I.           PURPOSE
             To provide a standard operating procedure for performing patient decontamination on ambu latory,
             non-ambulatory, and deceased patients who have been exposed to an agent posing the risk of
             secondary contamination.


II.          EQUIPMENT NEEDED

             A.       Decontamination Supplies

                     Backpack decon tanks/sprayers                 8
                     Brushes - soft bristle                        4
                     Brushes - firm b ristle                       4
                     Toothbrushes                                 10
                     Sponges/Mitts                                10
                     5-gallon buckets                             20
                     Contain ment basins                           2
                     Backboards/Reeves stretcher                   4
                     Ivory soap
                     Bleach
                     Garden hoses                                4-6
                     PVC shower                                    2
                     Trash barrels                                10
                     Marker cones                                 18
                     Line tape
                     Towels                                      500
                     Tarps                                         8
                     Cut-All scissors                              8
                     Saw horses                                    8
                     Decontamination tent                          1
                     Decontamination trailer                       1
                     Water supply                                  1
                     Space clothing packs                        500
                     Spare SCBA/PAPRs                              2




11/ 05/ 10                                                                                                      3-E-1
                                                                                          City of Seattle
                                                                         Seattle Fire Department (SFD)
                                                             Metropolitan Medical Strike Team (MMST)
             B.         Medical Supplies

                       Oxygen face masks (10)
                       4 x 4‘s
                       4 x 9‘s
                       ABD d ressing
                       Suction vac (10)
                       Oxygen with regulator (10)
                       BVMs (10)
                       Triangle bandages
                       Cerv ical collars
                       Kling
                       3‘‘ tape
                       OP A irways (#5,3)
                       Antidote Kits (MARK I, cyanide)


III.         SETUP

             A.         Standard Method

                  1.      Procure needed equipment from storage trailer.

                  2.      Locate large 100 x 100 size flat, secure, protected area adjacent to the
                          hot zone and protected from the media and the public.

                  3.      The selected area should be positioned based upon ground/floor control
                          and wind/airflow direction.

                  4.      The decontamination area should be level or sloped toward the entrance.

                  5.      A minimum of two personnel should be assigned to set up the system.

                  6.      Cones and/or rope should be used to identify perimeter outline.

                  7.      Entry and exit points should be well marked.

                  8.      Sufficient disposal units should be available and in place for
                          contaminated clothing and equipment drop-off.

                  9.      The system should be laid out to be used for performing emergency,
                          secondary and/or definitive decontamination.
                  10.     Designated decontamination solution(s) should be mixed.

                  11.     Spare respiratory protection should be immediately available.

                  12.     The system may be modified to include the decontamination trailer as
                          one side of the decontamination area or be self-standing as a second
                          decontamination section.

11/ 05/ 10                                                                                                  3-E-2
                                                                                          City of Seattle
                                                                         Seattle Fire Department (SFD)
                                                             Metropolitan Medical Strike Team (MMST)


                  13.    The decontamination PVC shower may be used as an alternative to a
                         hose spray wash at one or more of the wash/rinse stations.

                  14.    Towels and clothing packs should be placed in a clean area along with
                         medical supplies.

                  15.    Reasonable efforts for the circumstance should be initiated to control
                         runoff; saving lives is the priority.


IV.          PROCESS

             A.         Every patient believed to have been exposed to an agent with a risk of
                        secondary contamination is to receive at minimum emergency
                        decontamination.

             B.         Patient Emergency Decontamination (strip and rinse)

                  1.     Ambulatory Patients

a. Will usually be done by entry team personnel.

b. Direct patients by voice, PA amplification and/or hand signals to the emergency
   decontamination area just inside the hot zone but away from the high-risk area.

c. Direct patients to remove their clothing down to their underwear.

d. As often as possible, place all personal effects in trash barrels, separating personal effects
   (wallets, rings, watches, ID, etc.) into clear plastic bags with the victim‘s name, or a
   unique identifying number (ex., triage tag, ticket, etc.) placed on the bags whenever
   possible.

e. Particulate matter should be vacuumed, brushed, or wiped off all contaminated areas.

f.    Using hand-held sprayers containing tepid water and/or a dilute bleach solution perform a
      1-minute rinse from head to toe.

g. Have victims close their mouths and eyes while being decontaminated.

                         h.    Proceed to the decontamination section.

                         i.    Patients that have completed on-scene emergency decontamination
                               shall be identified with white flagging tape, preferably on an upper
                               extremity.

                  2.     Non-Ambulatory Patients


11/ 05/ 10                                                                                                  3-E-3
                                                                                       City of Seattle
                                                                      Seattle Fire Department (SFD)
                                                          Metropolitan Medical Strike Team (MMST)


a. The entry team shall remove the victim from the high-risk area in the quickest way
   possible and carry the patient (preferably on a Stokes stretcher or backboard) to the
   peripheral edge of the hot zone, bordering the warm zone.

b. Remove the patient‘s clothing, cutting it off if necessary, down to the underwear.

c. Place the cloths in the trash barrel.

d. Particulate matter should be vacuumed, brushed, or wiped off.

e. Using the hand-held sprayer or hose line, rinse the patient with tepid water for 1 minute,
   beginning with the face and airway, then open wounds, followed by head-to-toe rinsing
   in a systematic fashion.

f.   When rinsing the face, close the mouth and pinch the nose shut.

g. Assure axilla, genitalia, and the back are rinsed.

h. Rinse the backboard unless switch to clean basin will be done before transfer to the cold
   zone.

i.   If a C-spine injury is suspected and a C collar is available, apply the collar as soon as
     possible.

j.   Unless secondary decontamination is to be done, pass the patient into decontamination
     alley to be quickly dried, covered, wrapped in an enclosing blanket, and then carried to
     the cold zone on a backboard.

k. Properly protected cold zone personnel will take the patient and render indicated patient
   care per MMST protocol.

l.   If a radiological agent is involved, the decontamination team should scan the patient with
     detection equipment and report the results to the treatment team.

                        m.   Patients that have completed on-scene emergency decontamination
                             shall be identified with white flagging tape, preferably on an upper
                             extremity.


             C.        Secondary Decontamination (rinse/wash/rinse)

                  1.    Ambulatory Patients

a. Depending on the patient‘s condition, the number of casualties, the environment and
   personnel resources, the decision may be made to perform secondary decontamination to


11/ 05/ 10                                                                                               3-E-4
                                                                                    City of Seattle
                                                                   Seattle Fire Department (SFD)
                                                       Metropolitan Medical Strike Team (MMST)
     more thoroughly clean each patient. This will be done in the warm zone decontamination
     area.

b. The patient will be washed from head to toe using water and Ivory soap (water, with flour
   or oatmeal, may be used if radiological agent is suspected) or dilute (.5%) bleach
   solution.

c. Soft bristle brushes or sponges should be used to clean the patient in a systematic fashion,
   starting at the head.

d. Brushing should be done in a fashion to remove the product but not lead to abrading or
   irritation of the skin.

e. The patient should be rinsed in a systematic fashion avoiding overspray and cross-
   contamination.

f.   Cover open wounds with dressings and/or bandages after decontamination is completed.

g. Eye irrigation should be conducted using normal saline running through a nasal cannula
   (placed over an anesthetized eye). A decontamination solution other than normal saline is
   not to be used to decontaminate a victim‘s eyes.

h. Have the patient dry off and put on a gown; then, direct them to the cold zone - treatment
   personnel.
i. If a radiological agent is suspected and detection equipment is available, perform head-to-
   toe sweep noting the level and reporting it to the Field HazMat Group Supervisor; who
   will then determine if further decontamination is warranted before proceeding into the
   cold zone.


             2.   Non-Ambulatory Patients

a. Depending on the patient‘s condition, the number of casualties, the environment, and
   personnel resources, the decision may be made to perform secondary decontamination to
   more thoroughly clean each patient.

b. A minimum of two decontamination personnel per patient will be needed to perform
   decontamination in this situation.

c. Once inside the decontamination alley, the patient, on a backboard, shall be placed atop
   two sawhorses over a containment basin.

d. The airway should be established and protected and oxygen administered via non-
   rebreather facemasks or with BVM.




11/ 05/ 10                                                                                            3-E-5
                                                                                         City of Seattle
                                                                        Seattle Fire Department (SFD)
                                                            Metropolitan Medical Strike Team (MMST)
e. The patient will be washed from head to toe using water and Ivory soap, or a dilute (.5%)
   bleach solution (water and flour or oatmeal may be used if a radiological agent is
   suspected).

f.   Soft bristle brushes or sponges should be used for washing in a systematic fashion.

g. Brushing should be done in a fashion to remove the product but not lead to abrading or
   irritation of the skin.

h. The patient should be rinsed in a systematic fashion avoiding overspray and cross-
   contamination.

i.   Open wounds should be covered with dressings and/or bandages after decontamination is
     completed.

j.   Assure the back, axilla, and genitalia are thoroughly washed and rinsed.

k. Carefully rinse the backboard, unless a rotation onto a clean board is planned before the
   patient is taken into the cold zone.

                       l.    Eye irrigation should be conducted using normal saline running
                             through either a nasal cannula (placed over an anesthetized eye).

m. If a radiological agent is suspected and detection equipment is available, perform a head-
   to-toe sweep noting the level and report it to the Field HazMat Group Supervisor and/or
   the treatment team.

n. Quickly dry off the patient and cover with a blanket in an encapsulatory fashion.

o. Before transferring the patient into the cold zone, remove all treatment equipment used
   on the patient and dispose of them in the trash barrels.

p. Transfer the patient to properly protected treatment personnel in the cold zone.



V.           DECONTAMINATION TRIAGE

             A.       In cases involving multiple patients, priority will be placed on

                     Emergency decontamination of ambulatory patients
                     Decontaminating conscious, non-ambulatory patients
                     Unconscious, non-ambulatory patients should be decontaminated.
                     Deceased victims are the lowest priority.




11/ 05/ 10                                                                                                 3-E-6
                                                                                          City of Seattle
                                                                         Seattle Fire Department (SFD)
                                                             Metropolitan Medical Strike Team (MMST)
             B.        Patients that have completed on-scene emergency decontamination shall
                       be identified with white flagging tape, preferably on an upper extremity.


VI.          MASS DECONTAMINATION

             A.        In cases involving extraordinary numbers of patients, the Task Force
                       Leader may decide to perform any of the following:

                  1.    Use the decontamination trailer and/or standard decontamination system.

                  2.    Procure 1½‖ to 1¾‖ hose lines and use a fine spray to rinse as many
                        people as possible en masse. Their clothing should be left where they
                        stand for eventual collection by law enforcement personnel. Patients
                        should be given a 1-minute rinse and directed to a designated
                        decontamination section or treatment area.

                  3.    Use a deck gun with wide-angle spray and rinse as many patients as
                        possible en masse similar to number 2 above.

                  4.    Use a combination of numbers 1, 2, or 3 above.

                  5.    Patients that have completed on-scene emergency decontamination shall
                        be identified with white flagging tape, preferably on an upper extremity.


VII.         RENDERING ADVANCED CARE

             A.        Patients exposed to suspected nerve gas and symptomatic shall be given
                       antidotes immediately, preferably through deconned skin, if possible, and
                       continue on through decon.

             B.        Patients requiring critical treatment (i.e., intubation, needle
                       decompression, etc.) will be removed from the decontamination alley for
                       the procedure to be performed safely and so as not to interfere with the
                       decontamination process of remaining personnel. Once completed, a
                       decision will be made by the Field Medical Group Supervisor whether to
                       return the patient for further decontamination or be wrapped in an
                       encapsulated blanket and sent to the cold zone.

             C.        Critical care patients will not be taken care of at the expense of those less
                       critically injured except in cases where an MMST member is involved.

             D.        Decisions concerning the degree of advanced care to be rendered will be
                       made by the Team Medical Section Chief in conjunction with the Medical
                       Director.


11/ 05/ 10                                                                                                  3-E-7
                                                                                   City of Seattle
                                                                  Seattle Fire Department (SFD)
                                                      Metropolitan Medical Strike Team (MMST)



VIII. Disposition OF THE DECEASED

             A. Law Enforcement Officials, absent exigent circumstances, will make the
                determination regarding the disposition of the deceased.

             B.    No deceased victim will be removed from the incident scene without first
                   being given both emergency and secondary decontamination in
                   coordination with the Law Enforcement Liaison and the primary law
                   enforcement agency.

         C. Victims who are receiving treatment and become deceased (Under Treatment
            Death) should be placed in a body bag and removed as soon as possible to the
            temporary morgue site, in coordination with the Law Enforcement Liaison
            and the primary law enforcement agency. The Medical Director is to be
            notified when an Under Treatment Death occurs.




11/ 05/ 10                                                                                           3-E-8
                                                                                             City of Seattle
                                                                            Seattle Fire Department (SFD)
                                                                Metropolitan Medical Strike Team (MMST)
                                               APPENDIX F

                             METROPOLITAN MEDICAL S TRIKE TEAM
                          TEAM MEMB ER DECONTAMINATION PROCEDUR E



I.           PURPOSE
             To provide a standard operating procedure for performing decontamination on personnel wearing
             personal protective equipment (PPE) who have been exposed to an agent t hat poses the risk of
             secondary contamination.


II.          EQUIPMENT RECOMMENdED

             A.       Decontamination Supplies

                     Backpack decon tanks/sprayers            8
                     Brushes - soft bristle                   4
                     Brushes - firm b ristle                  4
                     Toothbrushes                            10
                     Sponges/mitts                           10
                     5-gallon buckets                        20
                     Contain ment basins                      2
                     Backboards/Reeves stretcher              4
                     Ivory soap
                     Bleach
                     Garden hoses                           4-6
                     PVC shower                               2
                     Trash barrels                           10
                     Marker cones                            18
                     Line tape
                     Towels                                 500
                     Tarps                                    8
                     Cut-All scissors                         8
                     Sawhorses                                8
                     Decontamination tent                     1
                     Decontamination trailer                  1
                     Water supply                             1
                     Space clothing packs                   500
                     Spare SCBA/PAPRs                         2
             B.       Medical Supplies

                     Oxygen face masks
                     4 x 4‘s
                     4 x 9‘s
                     ABD d ressing
                     Suction vac
                     Oxygen with regulator
                     BVM
                     Triangle bandages
                     Cerv ical collars



11/ 05/ 10                                                                                                     3-F-1
                                                                                          City of Seattle
                                                                         Seattle Fire Department (SFD)
                                                             Metropolitan Medical Strike Team (MMST)
                       Kling
                       3‘‘ tape
                       OP A irways


III.         SETUP

             A.         Standard Method

                  1.      Procure needed equipment from storage trailer.

                  2.      Locate large 100 x 100 size flat, secure, protected area adjacent to the
                          hot zone and protected from the media and the public.

                  3.      The selected area should be positioned based upon ground/floor control
                          and wind/airflow direction.

                  4.      The decontamination area should be level or sloped toward entrance.

                  5.      A minimum of two personnel should be assigned to set up the system.

                  6.      Cones and/or rope should be used to identify perimeter outline.

                  7.      Entry and exit points should be well marked.

                  8.      Sufficient disposal units should be available and in place for
                          contaminated clothing and equipment drop-off.

                  9.      The system should be laid out to be used for performing emergency,
                          secondary and/or definitive decontamination.

                  10.     Designated decontamination solution(s) should be mixed.

                  11.     Spare respiratory protection should be immediately available.

                  12.     The system may be modified to include the decontamination trailer as
                          one side of the decontamination area or be self-standing as a second
                          decontamination sector.

                  13.     The decontamination PVC shower may be used as an alternative to a
                          hose spray wash at one or more of the wash/rinse stations.

                  14.     Towels and clothing packs should be placed in a clean area along with
                          medical supplies.

                  15.     Reasonable efforts for the circumstance should be initiated to control
                          runoff; saving lives is the priority.


11/ 05/ 10                                                                                                  3-F-2
                                                                                          City of Seattle
                                                                         Seattle Fire Department (SFD)
                                                             Metropolitan Medical Strike Team (MMST)

IV.          PROCESS

             A.        Personnel shall enter the decontamination area from the hot zone side.


             B.        Tools should be dropped on dirty side in the designated area.


             C.        A decontamination team member should confirm that personnel to be
                       decontaminated are O.K. and have adequate air supply. If a problem
                       exists, emergency decontamination is to be initiated.


             D.        Remove contaminant(s) as follows:

                  1.    Step into containment basin.

                  2.    Protective clothing should be examined for cuts and breaches.

                  3.    Initiate rinse/scrub/rinse of the PPE, beginning at the head and
                        systematically moving down towards the feet.

                  4.    Avoid overspray and splashing.


                  5.    Assure boots, gloves, kneecaps, and axilla are cleaned.

                  6.    Use a ―walker‖ for stabilization, if needed.

                  7.    Repeat rinse/wash/rinse until item is cleaned.

                  8.    Use the Decontamination Check if available.

                  9.    Move out of the spray/wash area.


             E.        Remove/replace respiratory protection.

                  1.    Open suit carefully first if vapor tight suit (Level A) is used.

                  2.    When the suit is unzipped, peel it back so that dirty side is faced inward
                        and, then, fold down.

                  3.    Changeover SCBA/or remove, placing the used item on dirty side.
                        Changeover of SCBA will require a decontamination team member‘s
                        assistance.


11/ 05/ 10                                                                                                  3-F-3
                                                                                             City of Seattle
                                                                            Seattle Fire Department (SFD)
                                                                Metropolitan Medical Strike Team (MMST)


                  4.    Changeover of a complete SCBA will be preferable to replacing just the
                        bottle.

                  5.    The facepiece shall be left in place.


             F.        Remove protective clothing.

                  1.    If possible, have the individual sit down in a chair. Removal should be
                        done primarily by a decontamination team member.

                  2.    Remove duct tape or bands if used.

                  3.    Remove outer glove; turn inside out.

                  4.    Fold down the suit to boot level.

                  5.    Remove boots; place them in the designated boot trash can.

                  6.    Complete the suit removal; place in designated trash can.



                  7.    Remove the facemask and place it in the designated trash can.

                  8.    Remove cold/heat vest, if used.


             G.        Remove outer personal clothing, if contamination is suspected.


             H.        Proceed to the decontamination shower, if required.


             I.        Dry off and redress into clean clothing.


             J.        Report to the Rehabilitation Section for rest, rehydration, and medical
                       monitoring.




11/ 05/ 10                                                                                                     3-F-4
                                                                                            City of Seattle
                                                                           Seattle Fire Department (SFD)
                                                               Metropolitan Medical Strike Team (MMST)
                                                APPENDIX G

                          METROPOLITAN MEDICAL S TRIKE TEAM MEMB ER
                           EMERGENCY DECONTAMINATION PROCEDURE



I.           PURPOSE
             To provide a standard operating procedure for performing emergency decontamination on an
             MMST member wearing personal protective equipment (PPE) who encounters an illness, injury,
             or suit breach while working in the hot or warm zone.


II.          EQUIPMENT RECOMMENDED

                 Backpack decontamination sprayer or
                 Hose line with water supply
                 Scissors
                 Backboard
                 Improvised containment basis (if possible)


III.         PROCEDURE

             A.       Announce ―Mayday, Mayday, Team Member Down‖ (indicate location)
                      on radio and/or PA system. If personnel are in the hot zone, the backup
                      team shall be activated and deployed, if needed, and bring the ―downed‖
                      MMST member to the MMST Decontamination Area.

             B.       Operations Section Chief directs operations.

             C.       Two decontamination team members will assume responsibility for the
                      decontamination in the warm zone.

             D.       Attempt to ascertain the nature of the problem (e.g., suit breach, heat
                      illness, etc.)

             E.       Lay the patient down, if necessary (on a backboard, if available).

             F.       Perform a quick head-to-toe rinse/wash/rinse of the PPE.



             G. Rapidly remove suit, cutting it, if necessary, and in a manner that minimizes
                contamination spread.

             H.       Assure patient airway is open.

             I.       Initiate cool-down of patient with water, if indicated.


11/ 05/ 10                                                                                                    3-G-1
                                                                                     City of Seattle
                                                                    Seattle Fire Department (SFD)
                                                        Metropolitan Medical Strike Team (MMST)


             J.   Apprise treatment personnel of situation and findings.

             K.   Initiate appropriate preliminary medical care (e.g., O 2 , BVM support, etc.)
                  and antidote administration (ex., Mark I) as soon as possible.

             L.   Transport patient to Team Medical Treatment Area, or as directed b y the
                  Team Medical Section Chief.




11/ 05/ 10                                                                                             3-G-2
                                                                              City of Seattle
                                                             Seattle Fire Department (SFD)
                                                 Metropolitan Medical Strike Team (MMST)
                                  APPENDIX H

                       METROPOLITAN MEDICAL S TRIKE TEAM
                       HUMAN DECONTAMINATION SOLUTIONS




I.           FOR UNKNOWN PRODUCTS

             A.             Solution A: Five percent (5%) sodium carbonate and
                            five percent (5%) trisodium phosphate. Mix four (4)
                            pounds of commercial- grade trisodium phosphate with each
                            ten (10) gallons of water.

             B.             Solution B: Solution containing ten percent (10%)
                            calcium hypochlorite. Mix eight (8) pounds with ten (10)
                            gallons of water.

             C.             Rinse Solution:        To be used for both solutions. Five
                            percent (5%) solution of trisodium phosphate with each ten
                            (10) gallons of water.



II.          FOR KNOWN PRODUCTS WITHIN THE 10 HAZARD CLASSES

             A.             Solution A: A solution containing five percent (5%)
                            sodium carbonate and five percent (5%) trisodium
                            phosphate.

             B.             Solution B: A solution containing ten percent (10%)
                            calcium hypochlorite.

             C.             Solution C: A solution containing five percent (5%)
                            trisodium phosphate, which can be used as a general-
                            purpose rinse.

             D.             Solution D: A dilute solution of hydrochloric acid (HCl).
                            Mix one (1) pint of concentrated HCl into ten (10) gallons
                            of water (acid to water only). Stir with wood or plastic
                            stirrer.




11/ 05/ 10                                                                                      3-H-1
                                                                                     City of Seattle
                                                                    Seattle Fire Department (SFD)
                                                        Metropolitan Medical Strike Team (MMST)
III.         GUIDELINE FOR SELECTING DEGRADATION CHEMICALS FOR
             SPECIFIC TYPES OF HAZARDS

             A.   Inorganic acids, metal processing wastes                                     Solution A

             B.   Heavy metals: mercury, lead, cadmium, etc.                                    Solution B

             C.   Pesticides, chlorinated phenols, dioxins, PCP‘s                               Solution B

             D.   Cyanides, ammonia, and other non-acidic inorganic wastes                      Solution B

             E.   Solvents and organic compounds such as trichloroethylene,             Solution C (or A)
                  chloroform, and toluene

             F.   PBBs and PCBs                                                         Solution C (or A)

             G.   Oily, greasy, unspecified wastes not suspected to be                          Solution C
                  contaminated with pesticides

             H.   Inorganic bases, alkali, and caustic wastes                                  Solution D




11/ 05/ 10                                                                                             3-H-2
                                                                                        City of Seattle
                                                                       Seattle Fire Department (SFD)
                                                           Metropolitan Medical Strike Team (MMST)
                                          APPENDIX I

                               METROPOLITAN MEDICAL S TRIKE TEAM
                                 MEDICAL TREATMENT PROTOCOLS


                                      TABLE OF CONTENTS

                                                                                                           Page

Chlorine
             Fact Sheet                                                                                    3-I-3
             Treat ment Protocol                                                                           3-I-4

Hydrocyanic Acid, Hydrogen Cyanide and Cyanogen Chloride
       Fact Sheet                                                                                          3-I-7
       Treat ment Protocol                                                                                 3-I-8

Methyl Isocyanate, Methylene Bisphenyl Isocyanate, and Methylene Dilosocyanate
        Fact Sheet                                                                                        3-I-11
        Treat ment Protocol                                                                               3-I-13

Mustard (Sulfu r Mustard)
        Fact Sheet                                                                                        3-I-17
        Treat ment Protocol                                                                               3-I-18

Nerve Agents
       Fact Sheet                                                                                         3-I-20
       Treat ment Protocol                                                                                3-I-21




11/ 05/ 10                                                                                                 3-I-1
                                                                                  City of Seattle
                                                                 Seattle Fire Department (SFD)
                                                     Metropolitan Medical Strike Team (MMST)
                                     FACT SHEET

                                         Chlorine

Military Designation: None

Description: Chlorine is found as an amber liquid or greenish-yellow gas with a very
characteristic irritating, pungent odor. Chlorine is severely irritating to the skin, eyes,
and respiratory tract. Although generally stored as a liquid, when released, the resulting
gas is about two times heavier than air.

Non-military Uses: Chlorine is used widely in industrial settings in the organic
synthesis and manufacture of antifreeze agents, solve nts, refrigerants, resins, bleaching
agents, and other inorganic chemicals. There is an exceptionally wide use of chlorine in
non-commercial and home settings as a cleaning agent, bleaching agent, bacteriostatic,
and disinfecting agent. Storage of this substance in a variety of liquid and granular forms
is widespread.

Military Use: Chlorine was first used by the German military on 22 April 1915 in a
cylinder-released gas attack that resulted in an estimated 15,000 Allied wounded and
5,000 Allied deaths. Because of its tendency to dissipate rapidly, very large
concentrations were required. Chlorine was weaponized in projectiles, mortars, and
bombs. There is no current chlorine weaponry.

Health Effects: Chlorine exposure causes an immediate severe irritation to the eyes and
mucous membranes. The upper airways are first involved with nose, throat, and sinus
irritation. The lower airways are irritated with severe cough and chest pain. There may
be nausea, vomiting, and fainting. Very high doses may ca use excess fluid to develop in
the lungs (pulmonary edema). Wheezing respiration is likely to occur in individuals with
previous asthma. Bronchitis often occurs, sometimes progressing to pneumonia. Chronic
exposures may increase the susceptibility to respiratory infections. High concentrations
also irritate the skin, causing burning, itching, and occasional blister formation. There is
no animal or human epidemiologic data suggesting that chronic chlorine exposure may
cause cancer or the occurrence of adverse developmental effects in the unborn fetus.

Environmental Fate: Chlorine is not persistent in surface water, ground water, or soil.
Oxidation of environmental organic materials occurs rapidly, reducing its concentration
rapidly. Dispersal of chlorine gas is rapid to the atmosphere.




11/ 05/ 10                                                                                          3-I-2
                                                                                      City of Seattle
                                                                     Seattle Fire Department (SFD)
                                                         Metropolitan Medical Strike Team (MMST)
                                  TREATMENT PROTOCOL

                                             Chlorine

I.           General

             Chlorine is found as a greenish- yellow gas. There is a pungent, acrid,
             characteristic odor. Sensitivity to the odor is below toxic levels; however, since
             some sensory adaptation occurs, repeat exposures are more likely to produce toxic
             effects. Exposures irritate eyes and central (upper) airways within minutes. Low
             doses produce some cough and choking sensation. Moderate doses also produce a
             sense of suffocation, hoarseness, and substernal pain. High doses also produce a
             severe dyspnea, with pulmonary edema, nausea, vomiting, headache, syncope also
             seen. Very high doses may produce sudden death without an obvious pulmonary
             lesion, possibly via laryngospasm. All recognized exposures should be referred
             for direct observation/care.


II.          Patient Evaluation

             A.     Victims should be immediately removed from the toxic environment by
                    fully masked personnel. Chemical protective clothing is required for
                    liquid/solution exposures.

             B.     Liquid contamination causes eye and skin burns on contact. Contaminated
                    clothing should be removed/disposed of.



III.         Treatment

             A.     Eyes: Liquid exposures should be flushed with copious quantities of
                    water; medical attention should be sought. Gas exposures, if symptomatic,
                    should be flushed with water. Medical attention should be sought if
                    symptomatic.

             B.     Skin: Liquid exposures should be flushed with copious quantities of water;
                    contaminated clothing should be removed/disposed of. Gas exposures
                    require no specific therapy unless symptomatic. Intense gas exposure
                    produces burns; wash with water.




11/ 05/ 10                                                                                              3-I-3
                                                                                        City of Seattle
                                                                       Seattle Fire Department (SFD)
                                                           Metropolitan Medical Strike Team (MMST)
             C.        Breathing: Evaluate respiration, cyanosis, bronchospasm.

                  1.    If apneic: CPR with intubation. Be aware that laryngospasm may be
                        present with intense exposures, hence intubation may be very difficult,
                        and tracheostomy could be required. Medical attention should be sought.

                  2.    If stridorous/hoarse: Consider intubation under direct vision since
                        laryngospasm may be imminent (see above). Medical attention should
                        be sought.

                  3.    If dyspnea/cough/chest tightness: Consider intubation for impending
                        pulmonary edema. Also consider possible bronchospasm sufficiently
                        severe to have so little air exchange that wheezes are absent. Medical
                        attention should be sought. Codeine-containing demulcents may help.
                        Be wary of sedation.

                        Note: The anatomical configuration of infants and children‘s airways
                        makes wheezing a less reliable indicator of bronchospasm. Severe
                        smaller airway constriction with resultant hypoxia may be present. Any
                        apparent infant or child distress should be immediately assessed with
                        oximetry.

                  4.    If bronchospasm: Provide aggressive bronchodilation:

                        Adult:
                        Inhaled albuterol: unit dose q 2 hr.
                        Steroids: methylprednisolone, load 120 mg, then 60 mg q 6 hr.
                        Theophylline: load 150 mg, then 30 mg/hr.

                        Infants and children (0-12 yr):
                        Inhaled albuterol: 0.15 mg/kg per nebulized dose up to 5 mg/20 minutes
                        for first 2 hr.
                        Steroids: methylprednisolone: 1 mg/kg q 6 hr.
                        Theophylline: 10 mg/kg/24 hr.

                        Elderly:
                        Inhaled albuterol: unit dose q 3 hr.
                        Steroids: methylprednisolone, load 125 mg, then 60 mg q 6 hr.
                        Theophylline (occasional use): load 100 mg, then 25 mg/hr.

                        If asymptomatic: Maintain direct observation for at least 1 hour; if
                        becomes symptomatic, treat as above. If still asymptomatic, lesser
                        observation for additional 12 hours since some bronchospasm may
                        appear late.




11/ 05/ 10                                                                                                3-I-4
                                                                                 City of Seattle
                                                                Seattle Fire Department (SFD)
                                                    Metropolitan Medical Strike Team (MMST)
                  If hypoxic from bronchospasm bronchodilators and supplemental
                  oxygen from pulmonary edema: oxygen may be utilized with positive
                  pressure (e.g., PEEP 5-7 cm or intubation).

             5.   If pulmonary edema (occurs with very severe exposures): Treat as
                  noncardiac pulmonary edema (Adult Respiratory Distress Syndrome or
                  ARDS) with PEEP 5-7 cm and/or intubation. Diuretic therapy risks
                  severe hypotension if intubation is required.

             6.   If infection: Inhalation exposures may produce pulmonary infiltrates,
                  fever, and white blood cell elevations leading to an erroneous diagnosis
                  of (presumed bacterial) pneumonia. Prophylactic antibiotics are not
                  indicated. Surveillance bacteriologic cultures are obtained anticipating
                  an approximate 50% risk of nosocomial pneumonia at days 3-6.

             7.   If pain: Airway discomfort may benefit from codeine. Be wary of
                  sedation.




11/ 05/ 10                                                                                         3-I-5
                                                                                 City of Seattle
                                                                Seattle Fire Department (SFD)
                                                    Metropolitan Medical Strike Team (MMST)
                                     FACT SHEET

             Hydrocyanic Acid, Hydrogen Cyanide and Cyanogen Chloride

Military Designations: AC (hydrocyanic acid) and CK (cyanogen chloride)

Description: Both of these substances are liquids, but they vaporize (evaporate) at about
73°F and 58°C, so they will be in the gaseous form under most temperate conditions. AC
has an odor of bitter almonds; CK is pungent. AC vapor is lighter than air, whereas CK
gas is heavier than air. Cyanogen chloride is quickly metabolized to cyanide once
absorbed into the body, and causes the same biological effects as hydrogen cyanide. In
addition, CK is irritating to the eyes, nose, and throat (similar to riot control agents),
whereas AC is nonirritating.

Non-military Uses: Large amounts of cyanide (most in the form of salts) are produced,
transported, and used by U.S. industry annually. Cya nide is used in fumigation,
photography, extraction of metals, electroplating, metal cleaning, tempering of metals,
and the synthesis of many compounds. It is released when synthetic fibers and plastics
burn.

Military Uses: The French and the English used small amounts of cyanide during World
War I, but the compound was not effective as a weapon because the amount needed is
large (and small munitions were used) and because cyanide, being lighter than air, drifted
away from the target. Japan allegedly used cyanide against China before World War II,
and Iraq allegedly used cyanide against the Kurds in 1988. The U.S. once had cyanide
munitions, but the known are believed to have been destroyed. However, some of these
munitions may have been abandoned at sites around the U.S. Small amounts of cyanogen
chloride were incorporated in chemical agent identification sets, which were also
abandoned.

Health Effects: Cyanide blocks the use of oxygen in cells of the body and thus causes
asphyxiation in each cell. The cells of the brain and the heart are most susceptible to
oxygen lack. High concentrations of vapor may cause a brief increase in rate and depth
of breathing (in 15 seconds), seizures (30 seconds), and cessation of breathing (3-5
minutes) and of cardiac activity (4-10 minutes), and death. A smaller concentration will
cause headache, flushing, light headedness, and other nonspecific effects. (In addition,
CK produces irritation of the eyes, the nose, and the airways.) Antidotes (nitrites and
thiosulfate) are very effective if administered in time. A large exposure may result in
prolonged neurologic damage, probably because of hypoxia. Chronic ingestion of
cyanide-containing foods (e.g., cassava, which is a staple in many parts of Africa) has
been associated with thyroid and nerve disturbances. Evidence does not suggest that
cyanides are carcinogenic.

Environmental Fate: Because of their volatility, these substances are not expected to
persist in surface water or soil.



11/ 05/ 10                                                                                         3-I-6
                                                                                       City of Seattle
                                                                      Seattle Fire Department (SFD)
                                                          Metropolitan Medical Strike Team (MMST)
                                  TREATMENT PROTOCOL

                  Hydrocyanic Acid, Hydrogen Cyanide and Cyanogen Chloride

I.           General

             A.     Patient should be removed from the toxic environment immediately.

             B.     These substances are very volatile, so there is little need for
                    decontamination if exposure was to vapor alone. If liquid was present,
                    remove patient‘s clothing; wash liquid off skin.

             C.     The effects of vapor from either form of cyanide appear within seconds to
                    a minute. If patient has no or only mild effects when seen 5 to 30 minutes
                    after exposure, he/she will need no treatment.

             D.     Severe cyanide poisoning produces metabolic acidosis. If cyanide
                    poisoning is suspected in a patient who does not have moderate or severe
                    acidosis, treatment for cyanide poisoning should not be delayed, but the
                    diagnosis should be reconsidered


II.          Patient evaluation (LEVEL OF CONSCIOUSNESS, RESPIRATORY
             RATE, HEART RATE)

             A.     Exposure to a high concentration: transient hyperpnea, followed by
                    convulsions (30 seconds after exposure), gradual decrease in respiratory
                    rate and depth to apnea (3-5 minutes), and cessation of cardiac activity (5-
                    8 minutes).

             B.     Exposure to lower concentration: flushing, headache, anxiety, agitation,
                    vertigo, feeling of weakness, nausea, muscular trembling (cyanogen
                    chloride may cause irritation of eyes, nose, and airways). Prolonged
                    exposure may lead to effects listed above.

             C.     Odor of bitter almonds may be detected (half of the population cannot
                    smell this); normal pupils (may be dilated in terminal stage); ‗‗cherry-red‘‘
                    skin (may not be present); diaphoresis; venules in fundus are same color as
                    arterioles; cyanosis occurs only after circulatory collapse and apnea.


III.         Treatment

             A.     For a mild exposure (conscious and breathing): observe; no antidotes;
                    oxygen may be given to young or old or in presence of heart disease in a
                    patient with mild symptoms.


11/ 05/ 10                                                                                               3-I-7
                                                                                          City of Seattle
                                                                         Seattle Fire Department (SFD)
                                                             Metropolitan Medical Strike Team (MMST)
             B.        Severe exposure (unconscious, not breathing): should immediately
                       receive 100% oxygen. Cardiac monitoring and evaluation of oxygen
                       saturation should be done when possible. (Saturation will be normal even
                       in severe casualty until terminal stage; however, additional oxygen may
                       assist in therapy.) Antidotes should be administered as soon as possible
                       (see below). It is important to note that pulse oximeter results are
                       completely unreliable in the setting of methemoglobinemia, which is
                       induced by amyl nitrite or sodium nitrite therapy.

                  1.    For a severe exposure: ventilate using bag-valve-mask with one ampule
                        of amyl nitrite (crushed) in bag; after several minutes, add another
                        (crushed) ampule; keep adding an ampule every several minutes. This is
                        a temporary measure until IV drugs can be given, but it may assist in
                        recovery.

                  2.    Administer 300 mg (10 ml) of sodium nitrite IV over 5 minutes. Flush
                        line. [Children's dose: 0.2-0.3 ml/kg, or 6-9 mg/kg of the 3% solution.
                        No separate recommendation for infants. For elderly, use adult dose
                        unless they are small and frail.] Be aware: Nitrites produce orthostatic
                        hypertension, but a patient who can stand does not need them.

                  3.    Follow with 12.5 grams (50 ml) of sodium thiosulfate IV. [Children's
                        dose: 0.4 mg/kg, or 1.65 ml/kg of the 25% solution. No separate
                        recommendation for infants. Adult dose should be used for elderly
                        unless they are small and frail. Use care giving nitrite in a patient with
                        hypertension or heart disease.] (Amyl nitrite, sodium nitrite, and sodium
                        thiosulfate are in the Pasadena (formerly Lilly) Cyanide Antidote Kit,
                        the latter two in ampules of 300 mg/10 ml and 12.5 grams/50 ml). Use
                        one-half dose in 20 minutes if no improvement. See instructions on top
                        of Antidote Kit box.

             C.        If patient continues to remain apneic, intubate and continue oxygen
                       through tube with assisted ventilation.

             D.        Transfer apneic or unconscious patients to medical facility.

             E.        Patients often recover rapidly unless CNS hypoxia has occurred.

IV.          Laboratory issues

             A.        Metabolic acidosis is common; should be treated with bicarbonate.

             B.        Monitor arterial pO 2 ; should be normal until near-terminal stage.




11/ 05/ 10                                                                                                  3-I-8
                                                                                 City of Seattle
                                                                Seattle Fire Department (SFD)
                                                    Metropolitan Medical Strike Team (MMST)
                                     FACT SHEET

  Methyl Isocyanate, Methylene Bisphenyl Isocyanate, and Methylene Dilsocyanate
                                      MDI

Military Designations or Military Unique Use: None

Description: Methylene Bisphenyl Isocyanate (MDI) is found as a solid in white to
yellow flakes. Various liquid solutions are used for industrial purposes. There is no odor
to the solid or the liquid solutions. The vapor is approximately eight times heavier than
air. This chemical is a strong irritant to the eyes, mucus membranes, skin, and respiratory
tract. This chemical is also a very potent respiratory sensitizer.

Non-military Uses: Very large quantities of MDI are produced, transported, and used
annually in the United States. Various industrial processes utilize MDI in production and
usage of (poly)urethane foams, lacquers, and sealants. MDI is a commonly used
precursor in the industrial production of insecticides and laminating materials.
Noncommercial uses of polyurethanes such as in isocyanate paints or in cutting of
uncured urethanes may also cause exposure. Thermal degradation of these substances
may produce MDI as a combustion by-product.

Health Effects: MDI as either a solid or liquid solution is a strong irritant to the eyes
and the skin, resulting in discomfort and burning sensation. Severe inflammation may
occur. Irritation of the respiratory tract results in cough, shortness of breath, and chest
pain. Very high concentrations may irritate the respiratory tract sufficiently to cause
excess fluid accumulation within the lung, resulting in very severe respiratory distress
and pulmonary edema. MDI vapor is a strong sensitizer of the respiratory tract. In some
individuals, particularly those with prior history of asthma, repetitive exposures, even to
very low doses, may trigger an asthmatic episode. Such sensitized individuals may also
experience asthma with subsequent skin or eye exposures. This sensitization may persist
indefinitely. Repeated or long-term exposure may result in permanent respiratory
problems. Repeated or long- term exposure of the skin may cause a skin rash. There are
no animal or human epidemiologic data that suggest that chronic MDI exposure may
cause cancer or the occurrence of adverse developmental effects in the unborn fetus.

Environmental Fate: Since the reported vapor pressure of Methyl Isocyanate (MIC) is
348 mm Hg at 20C, MIC is expected to remain almost entirely in vapor phase when
released into the atmosphere. MIC is susceptible to hydrolysis and photooxidation in the
atmosphere with a half- life of 11 days at an atmospheric concentration of 5.OE+5
hydroxyl radicals/M3 . In the aquatic media, MIC is rapidly hydrolyzed with half- lives of
20 and 9 minutes at 14 and 25C, respectively. The products of hydrolysis-N-
carboxymethylamine, methylamine, carbon dioxide, and N,N'-dimethylurea are nontoxic.
Due to its rapid hydrolysis in aqueous media, MIC is not expected to bioconcentrate or
bioaccumulate in the environment. MIC released to soil is hydrolyzed and the
degradative process is rapid in the presence of moisture. Hydrolysis minimizes
adsorption and volatilization of MIC from the soil, although these conditions are


11/ 05/ 10                                                                                         3-I-9
                                                                                City of Seattle
                                                               Seattle Fire Department (SFD)
                                                   Metropolitan Medical Strike Team (MMST)
favorable for its mobility. Depending upon the concentration of MIC in soil and
prevailing moisture conditions, volatilization from the surface soil may be a significant
environmental transport and fate process.




11/ 05/ 10                                                                                        3-I-10
                                                                                       City of Seattle
                                                                      Seattle Fire Department (SFD)
                                                          Metropolitan Medical Strike Team (MMST)
                                   TREATMENT PROTOCOL

 Methyl Isocyanate, Methylene Bisphenyl Isocyanate, and Methylene Dilsocyanate -
                                     MDI

I.           General

             MDI is found as a solid, which has a melting point of 37C. Vapor exposures
             occur with liquids containing dissolved solid. Gas exposures may occur with
             high-temperature volatilization.     Thermal decomposition produces carbon
             monoxide and oxides of nitrogen. Sensitivity to this substance (eye, nose
             irritation) occurs at concentrations five times higher than OSHA limits (0.2
             mglm3 ); hence toxic exposures may go unrecognized.

             Exposures lead to:

                 Irritant effects: Eyes, mucous membranes and skin may be irritated,
                  particularly with prolonged, repetitive, or intense exposures. High
                  concentrations may also produce cough, dyspnea, and lethal pulmonary
                  edema.

                 Sensitizing effects: Respiratory sensitization may occur, particularly in
                  individuals with known asthma, allergies, or recognized isocyanate sensitivity
                  (e.g., TDI).

II.          Patient Evaluation

             Victim should be immediately removed from the toxic environment by personnel
             in chemically protective clothing. Vapor or gas hazards should be anticipated with
             full (positive pressure) masks. Liquid/solid contamination should be corrected by
             clothing removal and soap and water decontamination.

III.         Treatment

             A.      Eyes: There is no specific therapy appropriate. Liquid/solid exposures
                     should be irrigated with copious quantities of water. Subsequently,
                     symptomatic individuals should seek medical attention.

             B.      Skin: There is no specific therapy appropriate. Liquids/solids should be
                     removed with soap and water. Single exposures are unlikely to create
                     rashes unless previously sensitized. Intense exposure may produce a
                     dermatitis and require referral.

             C.      Swallowing: Liquids/solids should be removed by induced vomiting in the
                     conscious victim or by lavage otherwise.



11/ 05/ 10                                                                                               3-I-11
                                                                                        City of Seattle
                                                                       Seattle Fire Department (SFD)
                                                           Metropolitan Medical Strike Team (MMST)
             D.        Breathing: Symptoms due to sensitivity may be delayed up to 8 hr after
                       exposure. Respiratory symptoms may appear with skin, ocular or GI
                       exposure in previously sensitized individual.

                  1.    If apneic: CPR, may require intubation for pulmonary edema. Consider
                        severe bronchospasm in previously sensitized victim.

                  2.    If stridorous/hoarse: Consider intubation under direct vision.

                  3.    If dyspnea/cough/chest tightness: Consider intubation for impending
                        pulmonary edema. Also consider possible bronchospasm sufficiently
                        severe to have so little air exchange that wheezes are absent. Medical
                        attention should be sought. Codeine-containing demulcents may help.
                        Be wary of sedation.

                        Note: the anatomical configuration of infants and children's airways
                        makes wheezing a less reliable indicator of bronchospasm. Severe
                        smaller airway constriction with resultant hypoxia may be present. Any
                        apparent infant or child distress should be immediately assessed with
                        oximetry.

                  4.    If bronchospasm:        Treat as asthma with inhaled albuterol.
                        Bronchospasm may be particularly severe, especially in previously
                        sensitized individuals.

                        Treat aggressively:
                        Adults:
                        Inhaled albuterol: unit dose q 2 hr or continuous neb 15 g/hr.
                        Steroids: methylprednisolone load 250 mg, then 80 mg q 6 hr.
                        Theophylline: load 150 mg, then 30 mg/hr.

                        Infants and children (0-12 yr.):
                        Inhaled albuterol: 0.15 mg/kg per nebulized dose up to 5 mg/20 minutes
                        for first 2 hr.
                        Steroids: methylprednisolone; 1 mg/kg q 6 hr.
                        Theophylline: 10 mg/kgl24 hr.

                        Elderly:
                        Inhaled albuterol: unit dose q 3 hr.
                        Steroids: methylprednisolone load 125 mg, then 60 mg q 6 hr.
                        Theophylline (occasional use): load 100 mg then 25 mg/hr.




11/ 05/ 10                                                                                                3-I-12
                                                                                   City of Seattle
                                                                  Seattle Fire Department (SFD)
                                                      Metropolitan Medical Strike Team (MMST)
             5.   Upper airway obstruction: This is very rarely seen and only with intense
                  exposures. Hoarseness and stridor suggest impending laryngospasm;
                  consider intubation under direct vision.

a. If pulmonary edema (may rarely occur with intense exposures): Treat as non-cardiac
   pulmonary edema (Adult Respiratory Distress Syndrome or ARDS see PHOSGENE).

b. If hypoxia (commonly from bronchospasm, rarely from pulmonary edema): Treat with
   above bronchodilation and oxygen.

c. If cough: Codeine-containing demulcents (tissue-soothing agents) may help. Be wary of
   sedation.

     [Note: cough typically indicates inadequately treated bronchospasm.]

d. If pain: Airway discomfort from irritant effect may benefit from codeine. Be wary of
   sedation.




11/ 05/ 10                                                                                           3-I-13
                                                                                  City of Seattle
                                                                 Seattle Fire Department (SFD)
                                                     Metropolitan Medical Strike Team (MMST)
                                      FACT SHEET

                               Mustard (Sulfur Mustard)

Military Designations: H; HD; HS

Description: Mustard is a ‗‗blister agent‘‘ that causes cell damage and destruction. It is
a colorless to light yellow to dark brown oily liquid with the odor of garlic, onion, or
mustard. It does not evaporate readily, but may pose a vapor hazard in warm weather. It
is a vapor and liquid hazard to skin and eyes, and a vapor hazard to airways. Its vapor is
five times heavier than air.

Non-military Uses: Sulfur mustard has been used as a research tool to study DNA
damage and repair. A related compound, nitrogen mustard, was the first cancer
chemotherapeutic agent and is still used for some purposes.

Military Use: Mustard was used extensively in World War I and was the largest
chemical casualty producer in that war. Mustard was used by Iraq against Iran in the
1980s. The United States. has a variety of munitions filled with sulfur mustard, including
projectiles, mortars, and bombs. It is also in chemical agent identification sets (which
may be on abandoned sites) and in ton containers.

Health Effects: Mustard damages DNA in cells, which leads to cellular damage and
death. Mustard penetrates skin and mucous membranes very quickly, and cellular
damage begins within minutes. Despite this cellular damage, clinical effects do not begin
until hours later; the range is 2 to 24 hours, but usually 4 to 8 hours. The initial effects
are in the eyes (itching or burning), the skin (erythema with itching and burning), and
airways (epistaxis, hoarseness, sinus pain, cough). After high doses, these may progress
to more severe effects in the eyes (corneal damage), skin (blisters), and damage to the
lower airways (dyspnea and productive cough). After absorption of a large amount, there
may be damage to the gastrointestinal tract (vomiting, diarrhea) and bone marrow
(damage to stem cells with cessation of production of white cells, red cells, and platelets).
There is no antidote. Epidemiological studies indicate that frequent exposure to mustard
over years may cause an increased incidence of cancer of the upper airways. An acute
exposure may cause persistent damage to airways (e.g., stenosis) and eyes (keratitis).
Animal studies suggest that mustard may have developmental effects.

Environmental Fate: Persistence of mustard in soil will depend on the soil type, the
amount of mustard, the depth of contamination, and weather conditions. Mustard
contamination of surface soil may persist for weeks, and deeper soil may remain
contaminated for years. Mustard is relatively insoluble in water; once dissolved,
however, it breaks down into less toxic products. Because of its relatively rapid
hydrolysis once in solution, mustard is not thought to be transported through the soil by
ground water.




11/ 05/ 10                                                                                          3-I-14
                                                                                City of Seattle
                                                               Seattle Fire Department (SFD)
                                                   Metropolitan Medical Strike Team (MMST)
                                     TREATMENT PROTOCOL

                                      Mustard (Sulfur Mustard)

I.           General

             A.    Mustard causes no immediate effects. The initial clinical effects of
                   mustard (which usually involve the eyes, the skin, and the airways) appear
                   2 to 24 hours (usually 4 to 8 hours) after exposure to liquid mustard or to
                   mustard vapor. However, liquid or vapor mustard penetrates the skin and
                   mucous membranes and damages cells within minutes of exposure, so
                   decontamination must be done immediately after exposure.

             B.    The patient should be immediately removed from the toxic environment.

             C.    If liquid contact, clothing should be removed and skin decontaminated
                   with 0.5% hypochiorite (1 part household bleach mixed with 9 parts
                   water), soap and cool water, or thoroughly flushed with water alone. Eyes
                   should be flushed with large amounts of saline. If exposure is to vapor
                   alone, remove clothing.

             D.    If there is a history of definite exposure, patient should be taken to medical
                   facility for observation.


II.          Patient evaluation: Initial effects (USUALLY 2 TO 24 HOURS AFTER
             EXPOSURE)

             A.    Eyes: irritation, feeling of grit in eye, redness.

             B.    Skin: erythema (will progress to blisters 1 to 4 hours later if exposure was
                   large).

             C.    Airways: irritation of nose, voice change, sinus pain, hacking cough.
                   (Very rarely a patient might inhale an extremely large amount and start to
                   have these effects plus dyspnea within 2 hours. This patient should be
                   intubated, and assisted ventilation with oxygen should be started. This
                   patient should be taken to the nearest pulmonary intensive care unit as
                   quickly as possible.)


III.         Treatment

             A. There is nothing to do for these patients until effects appear except to
                decontaminate. Tissue is damaged within minutes, so decontamination must
                be done immediately.




11/ 05/ 10                                                                                          3-I-15
                                                                                      City of Seattle
                                                                     Seattle Fire Department (SFD)
                                                         Metropolitan Medical Strike Team (MMST)
             B.   Eyes: Any commercial eye solution may relieve the irritation from a mild
                  exposure. More severe effects: A mydriatic b.i.d. or q.i.d. (depending on
                  the length of action of the drug): a topical antibiotic b.i.d.; vaseline on lid
                  edges b.i.d.; sunglasses if photophobia is present. Topical steroids within
                  the first 24 hours only may reduce inflammation. Control pain with
                  systemic, not topical, analgesics. Visual loss is usually due to lid edema
                  and blepharospasm, not eye damage.

             C.   Skin: A soothing lotion (e.g., calamine) for erythema. Leave small
                  blisters intact. Unroof large blisters and irrigate denuded area at least t.i.d.
                  followed by liberal application of topical antibiotic. Watch for infection.
                  Fluid requirements are much less than those for thermal burns; do not
                  overhydrate.

             D.   Airways: Steam inhalation and cough suppressants will generally relieve
                  mild symptoms. A chemical pneumonitis (increased temperature, white
                  blood count; chest x-ray findings) may develop after large exposure:
                  intubation, assisted ventilation with oxygen (and possibly with PEEP or
                  CPAP); bronchodilators; watch sputum at least daily for organisms (no
                  antibiotics until organism is identified).

             E.   Systemic absorption of a large amount of mustard may cause bone marrow
                  and gastrointestinal tract damage. Watch WBC, Hct daily; mustard
                  damages bone marrow.




11/ 05/ 10                                                                                              3-I-16
                                                                                  City of Seattle
                                                                 Seattle Fire Department (SFD)
                                                     Metropolitan Medical Strike Team (MMST)
                                      FACT SHEET

                                       Nerve Agents

Military Designations: GA, GB, GD, GF, and VX
Common Names: Tabun (GA); Sarin (GB); Soman (GD). None for GF and VX.

Description: Nerve agents are very toxic organophosphorus compounds that have
biological activity similar to that of many insecticides. Their volatilities range from that
of water to that of motor oil; they present a hazard from vapor and liquid. Under
temperate conditions, the liquids are clear, colorless, and mostly odorless. They cause
biological effects by inhibiting acetylcholinesterase, thereby allowing acetylcholine to
accumulate and cause hyperactivity in muscles, glands, and nerves.

Non-military Use: There is no non- military use. Threat of human exposure exists in
research laboratories, in storage facilities, and from terrorists.

Military Use: Nerve agents were first synthesized pre-World War II, but were not used
in that war. They were used by Iraq in its war with Iran. The United States has a large
stockpile of GA and VX in weapons; these are being destroyed.

Health Effects: Nerve agents are the most toxic chemical agents. Initial effects from
small amounts of agent differ depending on route of exposure. After a small vapor
exposure, there is the immediate onset of effects in the eyes (small or pinpoint pupil
(miosis), redness, eye pain, dim vision), the nose (rhinorrhea), and airways (some degree
of shortness of breath because of bronchoconstriction and secretions). After a small
liquid exposure, there may be an asymptomatic interval of up to 18 hours before the onset
of sweating and fasciculations at the site of the droplet, which may be followed by
nausea, vomiting, and diarrhea. After exposure to a large amount of nerve agent by either
route, there is sudden loss of consciousness, convulsions, copious secretions, apnea, and
death. There is usually an asymptomatic interval of minutes after liquid exposure before
these occur; effects from vapor occur almost immediately. Antidotes (atropine and
pralidoxime) are effective if administered before circulation fails. There is no evidence
that nerve agents cause cancer or developmental effects.

Environmental Fate: GB will react with water to produce toxic vapors. Open-pit
burning or burying is prohibited. GB mixes with water and would be mobile in surface
and ground water should a release occur; however, because of its rapid hydrolysis, it is
not a long-term water contaminant of concern. Most GB spilled will be lost by
evaporation; because of this there is no long-term impact on health and environment. VX
is moderately persistent in soil, and because it has low water solubility, it could be mobile
in surface and ground water systems.




11/ 05/ 10                                                                                          3-I-17
                                                                                        City of Seattle
                                                                       Seattle Fire Department (SFD)
                                                           Metropolitan Medical Strike Team (MMST)
                                     TREATMENT PROTOCOL

                                Nerve Agents (GA, GB, GD, GF, VX)

I.           General

             Nerve agents are extremely toxic chemicals that cause effects by inhibiting the
             enzyme acetylcholinesterase, allowing excess acetylcholine to accumulate. This
             excess neurotransmitter then produces overstimulation and causes hyperactivity in
             muscles, glands and nerves The nerve agents are GA (Tabun), GB (Sarin), GD
             (Soman), GF, and VX. Their effects are identical.

             Remove patient from contaminated atmosphere. If exposure was to vapor,
             remove clothing; if exposure was to liquid; remove clothing and wash skin with
             0.5% hypochlorite (1 part household bleach and 9 parts water), soap and water, or
             thoroughly flush with water alone.


II.          Patient evaluation

             If patient is conscious, note ventilatory status and ask about nausea. If
             unconscious, note ventilatory status and heart rate (heart rate may be high, low, or
             normal in a nerve agent casualty).

             Initial effects differ depending on whether exposure was to vapor or to liquid.

             A.        Vapor: Effects start within seconds to a minute or two.

                  1.    Mild to moderate: Miosis (possible redness in eye, eye pain, complaints
                        of dim or blurred vision, nausea), rhinorrhea, excess secretions, dyspnea
                        (mild to severe).

                  2.    Severe: Loss of consciousness, seizures, apnea, flaccid paralysis.

             B.        Liquid: Effects start in minutes (large exposure) to 18 ho urs (small
                       exposure) after an asymptomatic interval.

                  1.    Mild to moderate: Sweating and fasciculations at site of exposure;
                        nausea, vomiting, diarrhea; weakness.

                  2.    Severe: Same as for vapor, but after a 1- to 30- minute asymptomatic
                        interval.


III.         Treatment



11/ 05/ 10                                                                                                3-I-18
                                                                                         City of Seattle
                                                                        Seattle Fire Department (SFD)
                                                            Metropolitan Medical Strike Team (MMST)
             A.        Initial Management

                  1.    Mild to moderate: Dyspnea should be treated with one or two doses of
                        atropine IM or IV and 1 dose of pralidoxime (IV drip) initially,
                        depending on severity of the dyspnea. (See paragraph B below for size
                        of dose.) This should be supplemented with oxygen, particularly in
                        infants, young children, and the elderly; healthy older children and
                        adults will usually do well without it unless they have pulmonary or
                        cardiac disease. Atropine dose should be repeated at 7-to 10- minute
                        intervals until improvement is noted. Failure to respond, (i.e., no dry
                        mouth, no decrease in secretions) confirms the need to administer
                        additional doses of atropine. Gastrointestinal effects after liquid
                        exposure are treated in the same manner. Do not treat for miosis (unless
                        eye pain is severe) or rhinorrhea (unless severe).

                  2.    Severe: Administer three doses of atropine IM (not IV in hypoxic
                        patient) and start one dose of pralidoxime by slow (20 minutes) IV drip.
                        (More rapid administration will cause hypertension.) (See paragraph B
                        below for size of dose.) Intubate and ventilate with oxygen (initial
                        ventilation will be difficult because of airway resistance; atropine will
                        relieve this). Administer diazepam if convulsing. Suction for
                        secretions. Repeat 1 dose of atropine (IM until hypoxia is improved,
                        then IV) every 5 minutes until (a) secretions diminish or (b) airway
                        resistance is less or is normal. Failure to respond,( i.e., no dry mouth, no
                        decrease in secretions) confirms the need to administer additional doses
                        of atropine. Monitor via pulse oximeter; cardiac monitoring should also
                        be done (cardiac arrhythmias are uncommon after atropine is given).
                        Acidosis may develop after seizures or after period of hypoxia and will
                        require therapy. This patient should be transported to a hospital after
                        stabilization (adequate drug therapy and initiation of ventilation).

                  3.    Eyes: Do not treat miosis unless eye/head pain is severe. Use topical,
                        not systemic, anticholinergic to relieve pain.

             B.        Recommended Doses

                  Atropine:
                     Older child and adult: 2 mg Infant and young child: 0.02 mg/kg
                     Elderly: Use adult dose unless cardiac or pulmonary disease is present or
                     patient is small or frail; in latter instances, use 1 mg as standard, but be
                     prepared to administer additional amounts more frequently.

                  Pralidoxime (2-PAM):
                     Older child and adult: 1 gram Infant and young child: 25-50 mg/kg
                     Elderly: Adult dose unless cardiac or renal disease is present, patient has
                     hypertension, or patient is small and frail; decrease dose by half in these
                     patients, but administer the other half 1 hour later if patient has not

11/ 05/ 10                                                                                                 3-I-19
                                                                                       City of Seattle
                                                                      Seattle Fire Department (SFD)
                                                          Metropolitan Medical Strike Team (MMST)
                       improved. Pralidoxime can cause hypertension when given rapidly IV.
                       Slow admin- istration over 20 minutes will minimize the hypertensive
                       effect. After rapid administration, hypertension can be rapidly but
                       transiently reversed by phentolamine (adult: 5 mg IV. child: 1 mg, IV).


             C.        Further Care

                  1.    Mild to moderate: After vapor exposure, a patient who is breathing
                        normally does not need to be hospitalized as he will not worsen.
                        However, miosis should be followed until eyes are normal (4 to 6
                        weeks). After liquid exposure, a patient should be observed in hospital
                        for 18 hours until all agent is absorbed from skin.

                  2.    Severe: Continue to ventilate and to administer atropine following
                        guidelines above. Treat acidosis if present. If patient has not had
                        prolonged hypoxia, recovery of an unconscious patient will be gradual
                        over l to 3 hours.




11/ 05/ 10                                                                                               3-I-20
                                                                                      City of Seattle
                                                                     Seattle Fire Department (SFD)
                                                         Metropolitan Medical Strike Team (MMST)
                                          APPENDIX J

            SIMPLE TRIAGE AND RAPID TREATMENT (START) SYSTEM


   I.      DEFINITION AND HISTORY:

        Triage – from the French, meaning ―to sort‖, ―to choose‖, ―to pick‖.

First utilized in the military to determine which wounded to treat based upon the severity of
        wounds and on chances of survival.

The first arriving unit at a Multiple Casualty Incident (MCI) is often confronted with a
       situation in which the number of patients and the severity of the injuries overwhelms
       the rescuers‘ ability to treat everyone at once. In these situations, TRIAGE must be
       initiated in order to do the greatest good, for the greatest number of patients. This
       means that historical and traditional approaches to patient care will not be possible
       and that while everyone expects a situation like this to arise in a ―Disaster‖ with 200-
       400 patients, it may be much more common in incidents involving only 4-6 patients.

A number of questions will plague the first-responding unit: How should we respond? What
      are our duties? Should we initiate CPR on the first person found in cardiac arrest?
      There may be times when CPR is appropriate and times when it is impossible. The
      number and condition of the patients will dictate both of these situations.

The first priority is to bring order to chaos. Until back-up help arrives, those patients in most
        urgent need of assistance must be identified and this can only be performed using a
        QUICK and SIMPLE method of TRIAGE.


   II. DUTIES OF THE TRIAGE OFFICER

The Triage Officer is traditionally the driver on the first arriving medic unit. Their first
      priority is to perform a quick scene assessment and size-up, noting potential hazards
      and dangers, requesting additional manpower and equipment, and obtain a rough
      estimate of patients. At the same time, TRIAGE must be initiated. With this in mind,
      it may be necessary for the TRIAGE OFFICER to direct his partner to start the
      TRIAGE while he/she completes his other responsibilities. Every patient must be
      counted and triaged. The TRIAGE OFFICER does not engage in patient treatment
      but if time permits, he/she must initiate re-triaging of those patients still not
      evaluated.

Keep in mind that at most MCI‘s, patients will walk away or run toward responding vehicles,
       thus creating additional challenges and hazards.




   11/05/10                                                                                   3-J-1
                                                                                       City of Seattle
                                                                      Seattle Fire Department (SFD)
                                                          Metropolitan Medical Strike Team (MMST)
   III. IDENTIFYING PATIENTS

         Patients are to be triaged and marked with a tagging system using colored plastic
         surveyor‘s tape. The tape is to be tied to the patient, preferably to the upper arm. Use
         sufficient lengths to leave about six inches after tying the knot so that it is readily
         visible. This tape is cheap, waterproof, easily applied and easily changed if the
         patient‘s condition warrants a change of TRIAGE status. The tape colors correspond
         with traditional TRIAGE color codes:

                RED = Immediate or Urgent Care.
                YELLOW = Delayed Care, patient can wait.
                GREEN = Non- injured or Walking Wounded.
                BLACK = DEAD or Non-Salvageable.
                WHITE = Emergency decontamination completed.


   IV.          IMPLEMENTATION OF THE START SYSTEM

The START system relies on three primary TRIAGE criteria:

                R – RESPIRATION‘S: Does the patient breath? What is the rate?
                P – PERFUSION: Does the patient have a radial pulse?
                M – MENTATION: Can the patient follow a simple command?

         Using these three, simple criteria, each patient should be evaluated in 60 seconds and
         ideally, in 10-15 seconds. Mistakes will be made and patient‘s status may change,
         therefore the TRIAGE OFFICER must re-triage, re-assess each patient as time
         allows.

         Early trauma deaths are caused by a disruption of the respiratory system, the vascular
         system and the central nervous system. The START triage plan is designed to
         quickly evaluate these three systems: Is the patient ventilating? Does the patient have
         a peripheral pulse? Does the patient have an altered level of consciousness?


         A) SCENE CONTROL

   The rapid establishment of the MCI scene will provide a number of important factors:

                Greater safety for patients and rescuers.
                Increases opportunity to maximize existing, available manpower and
                 equipment.
                Provides greatest ease for evacuation of patients and ultimately their
                 transportation.
                Eases communication within the MCI setting.



   11/05/10                                                                                    3-J-2
                                                                                 City of Seattle
                                                                Seattle Fire Department (SFD)
                                                    Metropolitan Medical Strike Team (MMST)
      It is the responsibility of the TRIAGE OFFICER to initially direct arriving
      personnel to assist in triage until that task is under control. At the same time,
      people must begin evacuating patients to treatment areas based on their triage
      color category.

      The first step is to identify those patients who are able to walk. People who can
      walk rarely have life-threatening injuries. Address the scene and instruct all
      patients who can walk to get up and walk to a designated, safe area. This group
      will have to be re-Triaged later but in the meantime, it quickly separates the
      GREEN patients. If possible, give one patient in this group GREEN tape and
      instruct them to tie a length on each patient. REMEMBER: These people should
      be kept nearby in order to utilize them as a source of emergency manpower to
      treat other patients!


            (1)       RESPIRATIONS

                  Patients without respiration = BLACK.
                  Patients who breathe after their airway is opened = RED.

           The patient is given one attempt to breathe spontaneously when their airway is
                  opened. The TRIAGE rescuer must not commit himself to any one
                  person therefore only one attempt is made to open the airway: by
                  positioning the head or clearing foreign material from the airway. If
                  the patient then breathes spontaneously, then a bystander or GREEN
                  patient might be utilized to maintain the position or the patient rolled
                  on their side. Usual, normal cervical spine precautions may have to be
                  ignored. In a TRIAGE situation, the sheer number of patients and the
                  importance of performing TRIAGE preclude otherwise normal
                  precautions.

                  Patients with respiration of 30/min. or greater = RED

                  This assessment must be rapid. Remember that one breath every two
                  seconds = 30/min. If in doubt, be conservative. Trust your instincts.
                  With practice, this assessment will be made quickly.

                  This first respiratory assessment has already categorized a number of
                  patients into RED = Urgent, or BLACK = ―Dead‖ triage groups.
                  Although checking mental status is last, it is obvious that by this time
                  all unconscious patients have been triaged based upon their respiratory
                  status, either RED or BLACK. If the patient‘s airway and respiratory
                  status is normal, or non-emergent, then move on to the next
                  assessment.




11/05/10                                                                                 3-J-3
                                                                                  City of Seattle
                                                                 Seattle Fire Department (SFD)
                                                     Metropolitan Medical Strike Team (MMST)

             (2)       PERFUSION – Pulse

                   Patients without a radial pulse = RED.

                   The radial pulse is used to assess perfusion. It is generally accepted
                    that a patient without a radial pulse has a blood pressure less than 80
                    mmHG, which indicates SHOCK.

                   NOTE: Direct pressure should be applied to any life-threatening
                   bleeding either by the victim or one of the GREEN/walking-
                   wounded patients. The TRIAGE rescuer may also assist the
                   patient in s hock by raising their lowe r extre mities.


             (3)       MENTAL STATUS – Mentation

                   Assess patient‘s mentation by asking them to perform a simple
                   command. Example: ―Open your mouth and stick out your tongue.‖
                   This tells the TRIAGE rescuer that not only can the patient process
                   simple information but that the patient is in control of their airway.

                   If the patient is unable to follow a simple command = RED.

                   If the patient is able to follow a simple command and has normal
                   respiration and a radial pulse = YELLOW.

                   Many people in MCI/Disaster situations are simply dazed or failed to
                   hear the initial instructions. At this point a patient might be asked to
                   get up and move over to the GREEN area and join that TRIAGE
                   group.

                   Remember that as a TRIAGE rescuer, one of the first observations
                   made about each patient is their level of consciousness, therefore, all
                   unconscious patients will be triaged RED or BLACK immediately
                   based on their ability to breathe. If doubt exists, ask them to follow a
                   simple command.

V.      CHILDREN IN TRIAGE

     Children present special challenges to the TRIAGE OFFICER when utilizing the
     START criteria. Remember that a child with a respiratory rate of 60+/min. = RED,
     the PERFUSION and MENTATION criteria is the same as an adult. In addition, the
     following are some guidelines to help in recognizing the child in distress = RED.




11/05/10                                                                                  3-J-4
                                                                                    City of Seattle
                                                                   Seattle Fire Department (SFD)
                                                       Metropolitan Medical Strike Team (MMST)
               Nasal flaring
               Grunting respirations
               Agitation/decreased level of consciousness/behavioral changes
               Pale mottle-cyanotic and cool, moist skin
               Evidence of significant blood loss

   VI.         RE-TRIAGE

Once all patients have been assessed and triaged, the need exists for the TRIAGE OFFICER
       to re-triage those patients still remaining at the scene. In any rapid assessment,
       mistakes may be made and since patient‘s status does change this is a very real need.
       Remember that if a triage status is changed, the old color tape must be removed and
       the new color applied.




   11/05/10                                                                                 3-J-5
                                                                                  City of Seattle
                                                                 Seattle Fire Department (SFD)
                                                     Metropolitan Medical Strike Team (MMST)

                                        APPENDIX 1
                                       QUICK REVIEW

          START – ―Simple Triage and Rapid Treatment‖

          TRIAGE – ―To sort‖, ―To choose‖.
           - Must be utilized whenever number of patients and severity of injuries
              makes it impossible for rescuers to treat everyone at once.
           - Purpose: Do the greatest good for greatest number! Separate patients into
              categories based on their chance of survival with treatment.

          TRIAGE OFFICER – EMT/EMS Officer on first arriving vehicle.
           - Responsibilities include: Scene assessment, size-up, request additional
              manpower and equipment, count patients.
           - Does not treat! If time permits, re TRIAGE!

          START Triage criteria: R,P,M.
           - R – Respirations – Does the patient breathe?
           - P – Perfusion – Does the patient have a radial pulse?
           - M – Mental Status/Mentation – Can the patient follow simple command?

          Scene Assessment: size-up, note hazards, request help, counts patients.

          Direct walking wounded and the uninjured to a specific point = GREEN
           patients

          Respirations:
           - If no respirations, open airway – does patient breathe? – NO = BLACK
           - Open airway – Does patient breathe? – YES = RED
           - If spontaneous respirations are present – 30+/min (1/2 second) = RED
           -   If respirations are normal (less than 30/min.) – next check.

Remember: Make only one attempt to open airway. Airway may be maintained by
     utilizing GREEN patients or positioning patients on their side.

          Perfusion: (Stop any life-threatening bleeding)
           - Is a radial pulse present? NO = RED
                                     YES = move onto the next check
           - Bleeding may be controlled by patient or other GREEN patients.

          Mental Status:
           - Can patient follow simple command, like ―Open your mouth!‖
                      NO = RED
                      YES = YELLOW



11/05/10                                                                                  3-J-6
                                                                                City of Seattle
                                                               Seattle Fire Department (SFD)
                                                   Metropolitan Medical Strike Team (MMST)
                                SEATTLE FIRE DEPARTMENT
SIM PLE TRIAGE AND RAPID TREATMENT(START )
                                               Able to Walk ?




                           NON                                                YES



              Assess RESPIRATIONS

                                                                                                     Tag GREEN
                                                                                                     DELAYED

            ABS ENT                             PRES ENT




   Reposition airway, if still apneic, tag                          Respiration RATE
                  BLACK.
  If breathing, tag RED IMMEDIATE.


                                                                                       Rate < 30 < 30
                                               Rate > 30   30


                                                                            Assess CIRCULATION

               Tag RED IMMEDIATE



                                                    Capill ary refill > 2                 Capill ary refill < 2
                                                       seconds or                          seconds or radial
                                                   NO RADIAL PULS E                       PULS E PRES ENT




                                                                                    Assess MENTA L STATUS

              Tag RED IMMEDIATE



                                             Unable to follow                           Follows commands
                                               commands


                                                                                                  Tag YELLOW
              Tag RED IMMEDIATE                                                                    DELAYED




11/05/10                                                                                 3-J-7
                                                                City of Seattle
                                               Seattle Fire Department (SFD)
___________________________________Metropolitan Medical Strike Team (MMST)

                                      APPENDIX K

                   METROPOLITAN MEDICAL STRIKE TEAM
                   EQUIPMENT STORAGE AND UTILIZATION

________________________________________________________________________
                                     __

   A.          INTRODUCTION

              The organization and management of a comprehensive equipment cache must
               not only meet the needs of on-scene operations, but also promote efficient
               packaging, handling, and transportation both to and from the disaster location.

              Efficient packaging, handling and transportation of cache tools, equipment,
               and supplies are fundamental to meeting the time constraints of response to
               NBC events.

              In order to meet the 90-minute operational requirement, all tools, equipment,
               and supplies should be prepackaged into a cache.

              Packaging for the MMST cache should be of modular design to provide the
               transporters options for handling the equipment.

              All MMST equipment should adhere to MMST inventory standards. This
               standardization will promote more efficient management and transportation
               of any or all MMST caches during multiple team responses.


   B.          PERSONAL

              Each MMST member is issued a ‗‗GO‘‘ kit of standard inventory equipment,
               which will be readily available at all times.

              This kit may consist of personal protective equipment (PPE) (respirator, suit,
               gloves, boots, glasses, helmet), team jumpsuit, auto-injectors (#), M-295 kit,
               M-8 paper, TLD badge, equipment bag and other equipment as needed.

              It is each member‘s responsibility to ensure that all issued equipment is
               inventoried regularly and to report to the Logistics Section any deficiencies.




11/05/10                                                                               3-K-1
                                                                City of Seattle
                                               Seattle Fire Department (SFD)
___________________________________Metropolitan Medical Strike Team (MMST)
   C.           MEDICAL EQUIPMENT

               An inventory of medical equipment will be found in Section 8 of this
                Operational System Description, called ―Equipment Cache Requirements‖.


   D.           PHARMACUTICAL

               A complete inventory of pharmaceuticals will be found in Section 10 of this
                Operational System Description, called ―Pharmaceutical Support‖.


   E.           CACHE PACKING

           The following standards are required for MMST caches:

                -   The cache will be divided into five elements. Color-coding will expedite
                    the sorting of containers during mobilization and on-site activities. The
                    following colors will be used to denote the various elements:

                       PPE                                                   Red
                       MEDICAL                                               Blue
                       DETECTION/SAMPLING                                    Yellow
                       LOGISTICS/COMMUNICATIONS                              Green
                       DECON                                                 White


               The ability to rapidly identify and package supplies and equipment is
                necessary to efficiently deploy and track cache items. This process is
                facilitated by adequately marking the following informatio n on each
                container:

                -   Inventory number of container
                -   Unit name
                -   Contents
                -   Color-coded identification of the equipment category


               In order to ensure security and avoid unnecessary damage to cache items, all
                containers should meet the following requirements:

                -   Constructed of high- impact material
                -   Weatherproofed
                -   Provided with handles or retractable handles
                -   Provided with stackable corners



11/05/10                                                                               3-K-2
                                                                     City of Seattle
                                                    Seattle Fire Department (SFD)
___________________________________Metropolitan Medical Strike Team (MMST)
           - Provided with fasteners to prevent accidental opening
           - Weigh not more than 150 pounds (gross weight of container and
              contents)
           - Easy to decontaminate

               The packaging of equipment into containers should be done not only for ease
                of handling during transport, but also with operational considerations in mind.


   F.           CACHE GROUND MOVEMENT AND DEPLOYMENT

               The Logistics Section Chief must plan for ground transportation requirements
            according to the cubic space and gross weight of the entire cache. Ground
            transportation during mobilization and while on site will require manual handling
            and loose loading of cache containers. Adhering to the container weight and size
            limitations will ensure overall manageability of the cache and is of paramount
            importance.

               The Logistics Section Chief is responsible for the assembly, management,
            and movement of the cache from its home jurisdiction to the staging area (or
            other area as directed by the Task Force Leader) during mobilization. This
            requirement should be fully defined, preplanned, and exercised prior to any actual
            mobilization. The following issues should be addressed:

                -   Process for assembling and packaging all cache tools, equipment, and
                    supplies (should the items not be maintained as a ‗‗stand alone‘‘
                    cache)
                -   Process for identifying, procuring, and packaging short shelf- life items
                    (e.g., batteries, fuels, drugs)
                -   Process for generating an inventory of all cache items

   G.           CACHE SUPPLEMENTATION

               Equipment may sometimes need to be replenished/replaced during on-site
                field operations (particularly extended operations). The Logistics Section
                Chief must ensure that this can be accomplished from an on-site command
                post. This may involve ordering equipment from a local supplier or obtaining
                equipment from local fire or Emergency Medical Services (EMS)
                departments.

               In a large-scale NBC event, it is likely that provisions will have to be made to
                restock local hospitals and medical facilities with critical antidotes and other
                pharmaceuticals. This may require a coordinated effort with the MMST
                Medical Director in contacting a pharmaceutical manufacturer for a special
                delivery or coordinating with DoD medical officials to obtain stocks from
                them.


11/05/10                                                                                 3-K-3
                                                                    City of Seattle
                                                   Seattle Fire Department (SFD)
___________________________________Metropolitan Medical Strike Team (MMST)
         Agreements should be in place with pharmaceutical manufacturers to obtain
           products rapidly.


   H.           AIR MOVEMENT

           Air transport may be provided by DoD assets or by civilian agency.

           Transportation of cache equipment must follow IATA regulations.

           Civilian aircraft may have to be manually loaded in lower cargo holds. Military
            aircraft will require palletization of all cache containers and personal equipment.

           MMST Logistics Specialists shall identify the weight and volume of all
            containers, equipment, and supplies in the cache prior to mobilization.

           Consideration must be given to supplies that must be shipped in pressurized
            atmospheres.


   I.           ACCOUNTABILITY/RESOURCES TRACKING

           The MMST must rely on the availability and readiness of equipment to support
            on-scene operations. A comprehensive property accountability system is essential
            for ensuring that equipment readiness is maintained. A system for accountability
            must be developed before any mobilization to ensure cache readiness. Ongoing
            maintenance and exercise of the cache equipment must be ensured for operational
            readiness between mobilizations. As such, there must be an organized system of
            equipment inventory, maintenance, and routine operation to ensure that the cache
            is ready for immediate response.

           The Logistics Specialist position has primary responsibility for property
            accountability and resource tracking during the mobilization, mission operation,
            and demobilization phases. This position tracks, distributes, maintains, and
            accounts for all equipment for the team.

               Personnel cannot remove equipment from the cache without coordinating
                with Logistics personnel.

               Post-mission inventory and status check procedures are extremely important
                for the subsequent readiness of the cache. All items must be inventoried,
                cleaned, overhauled, and checked for damage prior to return to storage. This
                information must be transferred to the inventory database.

               The Logistics Specialist(s) will ensure that all inventories are completed
                annually and after each deployment. Records of deficiency will be forwarded


11/05/10                                                                                3-K-4
                                                                   City of Seattle
                                                  Seattle Fire Department (SFD)
___________________________________Metropolitan Medical Strike Team (MMST)
           to the MMST TFL and the appropriate replacement equipment obtained as
           soon as possible.

              Critical equipment that will keep the MMST from operating will be replaced
               immediately.




11/05/10                                                                           3-K-5
                                                                                     City of Seattle
                                                                    Seattle Fire Department (SFD)
                                                        Metropolitan Medical Strike Team (MMST)
                  METROPOLITAN MEDICAL STRIKE TEAM (MMST)

                                TRAINING REQUIREMENTS


I.           INTRODUCTION

       A.     The Metropolitan Medical Strike Team (MMST) is intended to provide a level
              of technical expertise and proficiency not normally found in current civilian
              emergency response organizations. To be prepared to respond to incidents
              involving nuclear, biological, or chemical (NBC) agents, MMST personnel
              must be skilled in the identification of such agents. Additionally, MMST
              members must be capable of self-protection, treatment, decontamination, and
              operating in an NBC environment.

       B.     MMST personnel must also be skilled in providing technical advice and
              information to the Incident Commander (IC) in order to protect supporting
              emergency response personnel.

       C.     MMST personnel must also possess the knowledge required to provide
              instruction and assistance to the jurisdictions‘ supporting institutions and
              agencies to ensure that once casualties are removed from the incident scene,
              those providing care can do so effectively and without the threat of becoming
              secondary casualties.

II.          TRAINING GUIDELINES

       A.     Initial training will be commensurate with the member‘s specific assignment in
              the MMST.

       B.     Technical NBC training will be obtained from all available existing sources
              until such time as appropriate training materials and programs are developed for
              the MMST.

       C.     Cross-training to enhance the operational capabilities of team members is a
              desired goal and will constitute an element of annual team member refresher
              training.

       D.     Once team members meet initial required training objectives, training will be
              provided to supporting emergency response personnel and institutions.


III.         TRAINING PHILOSOPHY

       A.     Training specified for MMST members will ensure that each team member is
              sufficiently technically proficient to safely and effectively deal with the
              consequences of an NBC incident in addition to demonstrated proficiency in the


11/ 05/ 10                                                                                      4-1
                                                                                      City of Seattle
                                                                     Seattle Fire Department (SFD)
                                                         Metropolitan Medical Strike Team (MMST)
              areas of Hazardous Materials (HAZMAT) Response, Emergency Medical
              Treatment, Incident Management, and appropriate Law Enforcement areas.

      B.      Personnel assigned to the MMST will be required to meet all prerequisites
              mandated by the Federal Government and respective States for minimum
              qualifications for HAZMAT, Emergency Medical Technician, Incident
              Management, and Law Enforcement Officers.

      C.      Emergency Medical and Law Enforcement personnel assigned to the team must
              be trained to HAZMAT awareness and operational levels per their State and
              Federal standards, and each MMST member must receive appropriate training
              for the personal protective equipment (PPE) that will be used.


IV.          TRAINING PROGRAMS

      A.      Training programs currently available for all MMST members to provide the
              technical knowledge necessary to ensure self-protection and the ability to
              effectively deal with NBC agents are listed in Appendix 1. The recommended
              approach is to utilize existing training and certification programs to facilitate
              training until such time that MMST-specific training programs may be
              developed and made available. Ideally, NBC modules will be prepared to
              augment existing HAZMAT programs.

      B.      At a minimum, all training shall be in accordance with nationally recognized
              standards for HAZMAT emergency responders and will satisfy the
              Occupational Safety and Health Administration (OSHA) requirements for
              emergency response to HAZMAT incidents. Where respective State or local
              jurisdictions have more stringent standards than those proscribed by OSHA, the
              more stringent standards shall be met.


V.           HAZARDOUS MATERIALS TRAINING

      A.      By definition, under the OSHA, NBC agents are considered to be hazardous
              materials. The OSHA requirements for HAZMAT emergency response can be
              found in 29 CFR 1910.120 (q). The training requirements are task specific. All
              personnel assigned to the MMST will receive an appropriate level of HAZMAT
              training.

      B.      The National Fire Protection Association (NFPA) has published standards that
              closely mirror the OSHA standards but go into specific training requirements.
              The OSHA standards are more general than the NFPA and list minimum
              training hours. Experience has shown that training to comply with the NFPA
              will require a much greater time commitment than necessary to meet minimum
              OSHA standards; however, NFPA standards must be met if the MMST
              members are to be proficient.

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                                                                              City of Seattle
                                                             Seattle Fire Department (SFD)
                                                 Metropolitan Medical Strike Team (MMST)

             1.     The following NFPA standards cover HAZMAT emergency
                    response:

                    NFPA 471 – HAZMAT Response Standards
                    NFPA 472 – HAZMAT Training
                    NFPA 473 – HAZMAT Emergency Medical Services (EMS)

                  Currently, the NFPA 472 standards are under revision and will include
             some specifics for HAZMAT EMS, if adopted.


             2.     The Department of Transportation (DOT), under the Hazardous
                    Materials Transportation Act (HMTA), has published a document
                    that identifies the required training and recommended training for
                    each type of emergency responder. This document, titled the
                    ‗‗Guidelines for Public Sector Hazardous Materials Responders,‘‘
                    also includes other recommended training proposed by the Author
                    Group. The Author Group is coordinated under the Federal
                    Emergency Management Agency (FEMA).

             3.     HAZARDOUS MATERIALS TRAINING REQUIREMENTS

                    Hazardous Materials Training levels are listed below as Levels 1
                    through 5. Each numbered level currently has a recognized
                    training course or program. State and Department equivalents are
                    acceptable.




11/ 05/ 10                                                                               4-3
                                                                          City of Seattle
                                                         Seattle Fire Department (SFD)
                                             Metropolitan Medical Strike Team (MMST)
             Level 1

                OSHA – HazMat First Responder Awareness.
                TASK – For individuals who may discover a HazMat incident and
                take no action other than notification of appropriate authorities.
                NFPA – 472 awareness, 473 EMS Level I.
                RECOMMENDED FOR: All MMST Team members.

             Level 2

                OSHA – HazMat First Responder Operations.
                TASK – For individuals who may respond to a HazMat incident and
                operate in a defensive fashion. This includes working defensively in
                the Hot Zone and working in the Warm Zone (DECON).
                NFPA – 472 Operations, 473 EMS Levels I & II.
                RECOMMENDED FOR: All MMST Team members.

             Level 3

                OSHA – HazMat Technician.
                TASK – For individuals who may respond to a HazMat incident and
                operate in an offensive fashion.
                NFPA – 472 Technician.
                RECOMMENDED FOR: All Fire Service Team members.

             Level 4

                OSHA – HazMat Specialist.
                TASK – Same as technician, but with additional training.
                NFPA – 472 Technician.
                RECOMMENDED FOR: Fire Service HazMat Technicians.

             Level 5

                OSHA – HazMat Incident Management.
                TASK – IC, members of the general staff, and safety officers.
                NFPA – 472 HazMat Incident Management.
                RECOMMENDED FOR: All MMST Command and General Staff
                Members.




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                                                                                       City of Seattle
                                                                      Seattle Fire Department (SFD)
                                                          Metropolitan Medical Strike Team (MMST)
VI.          OTHER SELECTED EMERGENCY RESPONSE TRAINING

             Other selected training levels are listed below as Levels 6 through 13.

                    Level 6

                        Confined Space Training
                        RECOMMENDED FOR: All Fire Service Personnel..

                    Level 7

                        Self-contained Breathing Apparatus Training
                        RECOMMENDED FOR: All MMST Team members except Medical
                        Director and Hospital Liaison.

                    Level 8

                        Safety Officer
                        RECOMMENDED FOR: All MMST Command and General Staff
                               Team.

                    Level 9

                        Firefighter Levels I and II, NFPA or equivalent
                        RECOMMENDED FOR: All Fire Service Personnel.

                    Level 10

                        Emergency Medical Technician – Basic
                        RECOMMENDED FOR: All Fire Service Personnel.

                    Level 11

                        Emergency Medical Technician – Paramedic
                        RECOMMENDED FOR: All MMST Medical Specialist.

                    Level 12

                        EMS HazMat Training
                        RECOMMENDED FOR: All MMST EMT‘s.

                    Level 13

                        Recognized NBC Agent Training
                        RECOMMENDED FOR: All MMST Team members.




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                                                                                     City of Seattle
                                                                    Seattle Fire Department (SFD)
                                                        Metropolitan Medical Strike Team (MMST)
VII.         NBC AGENT TRAINING

             All MMST members will receive training in the following technical subject areas
             related to NBC agents.

             A.             Nuclear Training

                    1.      Basic Nuclear Radiation Fundamentals

                    2.      Self-Protection

                    3.      First Aid

                    4.      Detection and Monitoring

                    5.      Decontamination

                    6.      Emergency Medical Care

             B.             Biological Training

                    1.      Biological Agents

                    2.      Self-Protection

                    3.      First Aid

                    4.      Detection and Monitoring

                         5. Decontamination

                         6. Emergency Medical Care


             C.             Che mical Agent Training

                    1.      Chemical Agents

                    2.      Self-Protection

                    3.      First Aid

                    4.      Detection and Monitoring

                    5.      Decontamination



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                                                                                    City of Seattle
                                                                   Seattle Fire Department (SFD)
                                                       Metropolitan Medical Strike Team (MMST)
                   6.     Emergency Medical Care


VIII. TRAINING DOCUMENTATION

      A.      All MMST members will provide copies of current training certifications to the
              Plans Section Chief.

      B.      Records of team member training subsequent to documentation of initial
              certifications will be provided to the Plans Section Chief for inclusion in the
              team member‘s MMST membership file.


IX.          TRAINING COURSES AND COURSE MATERIALS

      A.      Some available training information and points of contacts are listed in
              Appendix 2.

      B.      Organizations seeking training must determine the qualifications of potential
              training based upon careful review of the organizational status and need.
              Determination of qualifications should include a detailed examination of OSHA
              and NFPA requirements.


X.                 MMST MEMBER’S PROFICIENCY TRAINING AND EXERCISES

     A.       It is essential that the MMST conduct team training and exercises to develop
              and maintain team proficiency.

     B.       Training shall be conducted by functional elements in accordance with the
              training schedule at Appendix 3. Functional element training will include
              operational checks on team communication, monitoring, detection, and PPE.

     C.       A minimum of one full team training exercise will be conducted annually. It is
              recommended that this exercise be integrated with jurisdictional HAZMAT or
              disaster exercises or with local hospital mass casualty drills.

XI.                MMST SYSTEM HOSPITAL PROVIDER TRAINING

             A.    Local and area hospitals will play an important role in responding to an
                   incident involving Weapons of Mass Destruction (WMD) or major
                   accidental hazardous materials incidents. The Seattle MMST Plan shall
                   include Awareness, Operations and Hospital Provider (WMD) training for
                   local hospital providers.




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                                                                                             City of Seattle
                                                                            Seattle Fire Department (SFD)
                                                                Metropolitan Medical Strike Team (MMST)
                 B.       Hospital preparedness training will be coordinated by the Washington
                          Hospital Association and include concepts of outside triage and mass
                          decontamination facilities, ―lockdown‖ concepts, and providing definitive
                          care while utilizing appropriate personal protective equipment (PPE) for
                          hospital staff.

                 C.       The Department of Defense ―Domestic Preparedness Program‖ will
                          provide baseline information on treatment protocols. The Medical
                          Director of the MMST will implement a program of WMD Awareness
                          that can be used during Hospital Staff meetings, grand rounds or in-service
                          training sessions.

                 D.       The intent is to have this program become an integral part of the hospitals
                          orientation and annual refresher programs.


    XII.         NON-TEAM MEMBER TRAINING NEEDS

                 Training in WMD-Awareness, Operations and Technician- levels will not be
                 limited to Seattle MMST members. The following groups of responders will need
                 training:

                         Initial Responders
                               1. Fire Service
                               2. Law Enforcement
                               3. HazMat
                               4. EMS, to include first responders, EMT‘s, paramedics, vehicle
                                   drivers and any other personnel who might be anticip ated to
                                   provide care for victims of a NBC incident.
                               5. Emergency Dispatchers
                               6. Jail Staff

                         Medical Community (hospitals, urgent care, stadium 1 st aid, etc.) to
                          include Emergency Room staff, security, facilities maintenance, etc.

                         Emergency Management to include local government officials, health
                          departments, etc.


XIII. MMST SYSTEM PERSONNEL TRAINING REQUIREMENTS

                 A.       All regional MMST system components and jurisdictions shall be invited
                          to sponsor student trainers for participation in an instructor training series
                          on NBC incident preparedness, response and management.                    The
                          Department of Defense will provide this training in addition to a limited
                          amount of training equipment.



    11/ 05/ 10                                                                                          4-8
                                                                                   City of Seattle
                                                                  Seattle Fire Department (SFD)
                                                      Metropolitan Medical Strike Team (MMST)
             B.   For those personnel who will be caring for victims of a terrorist attack
                  involving weapons of mass destruction, training above and beyond the
                  awareness program will be provided. This will include training specific to
                  decontamination, diagnosis, and treatment with specific antidotes. This
                  category of personnel shall include all of those engaged in the following
                  activities:

                     1. Patient Decontamination
                     2. Patient Triage
                     3. Patient Initial On Scene Treatment
                     4. Patient Transportation and Ongoing Medical care During
                        Transport
                     5. Providing Definitive Patient Care




11/ 05/ 10                                                                                    4-9
                                                                                City of Seattle
                                                               Seattle Fire Department (SFD)
                                                   Metropolitan Medical Strike Team (MMST)
                                      APPENDIX 1

              METROPOLITAN STRIKE TEAM TRAINING REQ UIREMENTS



POSITION                                    TRAINING COURSES

MMST PROGRAM DIRECTOR                       HAZMAT First Responder Awareness
(Seattle Fire Department Assistant Chief)   HAZMAT First Responder Operations
                                            HAZMAT Incident Management
                                            Firefighter Levels I & II, or equivalent
                                            Emergency Medical Technician – Basic
                                            NBC Agent Training

TASK FORCE LEADER                           HAZMAT First Responder Awareness
                                            HAZMAT First Responder Operations
                                            HAZMAT Technician
                                            HAZMAT Incident Management
                                            Self-contained Breathing Apparatus
                                            Safety Officer
                                            Firefighter Levels I & II, or equivalent
                                            Emergency Medical Technician – Basic
                                            EMS HAZMAT Training
                                            NBC Agent Training

LAW ENFORCEMENT LIAISON                     HAZMAT First Responder Awareness
                                            HAZMAT First Responder Operations
                                            HAZMAT Incident Management
                                            Self-contained Breathing Apparatus
                                            Safety Officer
                                            NBC Agent Training

SAFETY OFFICER                              HAZMAT First Responder Awareness
                                            HAZMAT First Responder Operations
                                            HAZMAT Technician
                                            HAZMAT Incident Management
                                            Confined Space Training
                                            Self-contained Breathing Apparatus
                                            Safety Officer
                                            Firefighter Levels I & II
                                            Emergency Medical Technician - Basic
                                            EMS HAZMAT Training
                                            NBC Agent Training




11/ 05/ 10                                                                                4-10
                                                             City of Seattle
                                            Seattle Fire Department (SFD)
                                Metropolitan Medical Strike Team (MMST)
POSITION                   TRAINING COURSES

MEDICAL DIRECTOR           HAZMAT First Responder Awareness
                           HAZMAT First Responder Operations
                           HAZMAT Incident Management
                           Safety Officer
                           EMS HAZMAT Training
                           NBC Agent Training
HOSPITAL LIAISON           HAZMAT First Responder Awareness
                           HAZMAT First Responder Operations
                           HAZMAT Incident Management
                           Safety Officer
                           EMS HAZMAT Training
                           NBC Agent Training
OPERATIONS SECTION CHIEF   HAZMAT First Responder Awareness
                           HAZMAT First Responder Operations
                           HAZMAT Technician
                           HAZMAT Incident Management
                           Confined Space Training
                           Self-contained Breathing Apparatus
                           Safety Officer
                           Firefighter Levels I & II
                           Emergency Medical Technician - Basic
                           EMS HAZMAT Training
                           NBC Agent Training
FIELD MEDICAL              HAZMAT First Responder Awareness
GROUP SUPERVISOR           HAZMAT First Responder Operations
                           HAZMAT Technician
                           Confined Space Training
                           Self-contained Breathing Apparatus
                           Firefighter Levels I & II
                           Emergency Medical Technician - Basic
                           Emergency Medical Technician – Paramedic
                           EMS HAZMAT Training
                           NBC Agent Training
MEDICAL SPECIALISTS        HAZMAT First Responder Awareness
(FIELD MEDICAL             HAZMAT First Responder Operations
& TEAM MEDICAL)            HAZMAT Technician
                           Confined Space Training
                           Self-contained Breathing Apparatus
                           Firefighter Levels I & II
                           Emergency Medical Technician – Paramedic
                           EMS HAZMAT Training
                           NBC Agent Training

FIELD HAZMAT               HAZMAT First Responder Awareness
GROUP SUPERVISOR           HAZMAT First Responder Operations
                           HAZMAT Technician
                           HAZMAT Specialist

11/ 05/ 10                                                             4-11
                                                                        City of Seattle
                                                       Seattle Fire Department (SFD)
                                           Metropolitan Medical Strike Team (MMST)
POSITION                              TRAINING COURSES

                                      Confined Space Training
                                      Self-contained Breathing Apparatus
                                      Firefighter Levels I & II
                                      Emergency Medical Technician – Basic
                                      EMS HAZMAT Training
                                      NBC Agent Training

FIELD HAZMAT SPECIALIST               HAZMAT First Responder Awareness
                                      HAZMAT First Responder Operations
                                      HAZMAT Technician
                                      HAZMAT Specialist
                                      Confined Space Training
                                      Self-contained Breathing Apparatus
                                      Firefighter Levels I & II
                                      Emergency Medical Technician – Basic
                                      EMS HAZMAT Training
                                      NBC Agent Training

PLANS SECTION CHIEF                   HAZMAT First Responder Awareness
                                      HAZMAT First Responder Operations
                                      HAZMAT Technician
                                      HAZMAT Incident Management
                                      Confined Space Training
                                      Self-contained Breathing Apparatus
                                      Safety Officer
                                      Firefighter Levels I & II
                                      Emergency Medical Technician - Basic
                                      EMS HAZMAT Training
                                      NBC Agent Training
PLANS GROUP SUPERVISOR                HAZMAT First Responder Awareness
                                      HAZMAT First Responder Operations
                                      HAZMAT Technician
                                      Confined Space Training
                                      Self-contained Breathing Apparatus
                                      Firefighter Levels I & II
                                      Emergency Medical Technician - Basic
                                      EMS HAZMAT Training
                                      NBC Agent Training

INFORMATION SPECIALISTS               HAZMAT First Responder Awareness
(Intelligence, HAZMAT, and Medical)   HAZMAT First Responder Operations
                                      Self-contained Breathing Apparatus
                                      EMS HAZMAT Training
                                      NBC Agent Training

LOGISTICS SECTION CHIEF               HAZMAT First Responder Awareness
                                      HAZMAT First Responder Operations

11/ 05/ 10                                                                        4-12
                                                               City of Seattle
                                              Seattle Fire Department (SFD)
                                  Metropolitan Medical Strike Team (MMST)
POSITION                     TRAINING COURSES

                             HAZMAT Technician
                             HAZMAT Incident Management
                             Confined Space Training
                             Self-contained Breathing Apparatus
                             Safety Officer
                             Firefighter Levels I & II
                             Emergency Medical Technician - Basic
                             EMS HAZMAT Training
                             NBC Agent Training

LOGISTICS GROUP SUPERVISOR   HAZMAT First Responder Awareness
                             HAZMAT First Responder Operations
                             HAZMAT Technician
                             Confined Space Training
                             Self-contained Breathing Apparatus
                             Firefighter Levels I & II
                             Emergency Medical Technician - Basic
                             EMS HAZMAT Training
                             NBC Agent Training

LOGISTICIANS                 HAZMAT First Responder Awareness
                             HAZMAT First Responder Operations
                             HAZMAT Technician
                             Confined Space Training
                             Self-contained Breathing Apparatus
                             Firefighter Levels I & II
                             Emergency Medical Technician - Basic
                             EMS HAZMAT Training
                             NBC Agent Training




COMMUNICATIONS               HAZMAT First Responder Awareness
GROUP SUPERVISOR             HAZMAT First Responder Operations
                             HAZMAT Technician
                             Confined Space Training
                             Self-contained Breathing Apparatus
                             Firefighter Levels I & II
                             Emergency Medical Technician - Basic
                             EMS HAZMAT Training
                             NBC Agent Training

COMMUNICATION SPECIALIST     HAZMAT First Responder Awareness
                             HAZMAT First Responder Operations

11/ 05/ 10                                                               4-13
                                                               City of Seattle
                                              Seattle Fire Department (SFD)
                                  Metropolitan Medical Strike Team (MMST)
POSITION                     TRAINING COURSES

                             HAZMAT Technician
                             Confined Space Training
                             Self-contained Breathing Apparatus
                             Firefighter Levels I & II
                             Emergency Medical Technician - Basic
                             EMS HAZMAT Training
                             NBC Agent Training

TEAM MEDICAL SECTION CHIEF   HAZMAT First Responder Awareness
                             HAZMAT First Responder Operations
                             HAZMAT Incident Management
                             Self-contained Breathing Apparatus
                             Safety Officer
                             EMS HAZMAT Training
                             NBC Agent Training




11/ 05/ 10                                                               4-14
                                                                               City of Seattle
                                                              Seattle Fire Department (SFD)
                                                  Metropolitan Medical Strike Team (MMST)
                                     APPENDIX 2

             SOURCES FOR TRAINING METROPOLITAN MEDICAL STRIKE TEAM



Training requirements for levels 1 through 13 can be obtained from the Seattle Fire
Department. Level 11 paramedic training is administered through the Medical Director
at Harborview Medical Center.

NBC agent training can also be obtained from various sources including, but not limited
to, the following: Department of Defense, Federal and State Governments, and
commercial vendors including colleges and universities.




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                                                                            City of Seattle
                                                           Seattle Fire Department (SFD)
                                               Metropolitan Medical Strike Team (MMST)
                                  APPENDIX 3

                       METROPOLITAN MEDICAL S TRIKE TEAM
                        TRAINING AND EXERCIS E SCHEDUL E



             SUBJECT                  FREQUENCY                     MINIMUM HOURS

HAZMAT Refresher                        Annually                                8
Personal Protective Equipment           Annually
Detection and Monitoring                Annually
NBC Refresher                           Annually

Communication                           Quarterly                             N/A
Team Activation                         Quarterly
Team External Communication             Quarterly
Team Internal Communication             Quarterly

Full-Scale Exercise                     Annually                                8
SARA HAZMAT                             Annually
Jurisdictional Disaster                 Annually
Hospital Mass Casualty                  Annually




11/ 05/ 10                                                                            4-16
                                                                                       City of Seattle
                                                                      Seattle Fire Department (SFD)
                                                          Metropolitan Medical Strike Team (MMST)
                        METROPOLITAN MEDICAL STRIKE TEAM

                            HEALTH AND MEDICAL SERVICES

              PART I: PRE-EVENT MEDICAL FACILITY COORDINATION


I.           PURPOSE

      The purpose of this section is to define the pre-event coordination necessary to
      ensure an organized medical response to nuclear, biological, or chemical (NBC)
      incidents. In an NBC event, there is every likelihood that large numbers of people
      will be affected. Therefore, it is advantageous for medical facilities to preplan their
      response to these types of incidents.

             A.   Medical Facilities

                  1.       Hospitals

                            a.     Number of Victims. In NBC incidents, large numbers of
                       victims will be affected to varying degrees. Many will not wait for
                       emergency transport but will self- refer to the closest known or available
                       medical facility. The majority will be transported by local Emergency
                       Medical Services (EMS) providers.

                           (1)    Each agency should be familiar with hospital response
                           plans for their areas, and each facility should be familiar with
                           regional plans for NBC events through plan review, meeting
                           attendance, and exercises.

                           (2)    If an event occurs, 911 centers will notify hospitals so that
                           they may activate their internal plans for managing these events.

                           (3)    It is also important that hospitals notify 911 centers if they
                           experience significant numbers of patients presenting with similar
                           or identical symptoms that would indicate that a
                           chemical/biological (C/B) event has occurred.

                           (4)    Hospitals and emergency responders must exchange
                           information via radio, fax, or phone early in the event. Such
                           information should include:




11/ 05/ 10                                                                                        5-1
                                                                           City of Seattle
                                                          Seattle Fire Department (SFD)
                                              Metropolitan Medical Strike Team (MMST)
                          Agent identification

                          Agent toxicology

                          Estimated number of victims involved

                          Decontamination procedures for the agent(s) involved

                          Pharmaceutical distribution plans

                 (5)    Hospitals should be prepared to indicate how many critical
                 and non-critical patients they can manage.           Emergency
                 departments should maintain basic treatment guidelines for the
                 types of NBC events likely to be seen.

                 (6)     Due to the potential number of victims in these scenarios,
                 Metropolitan Medical Strike Team (MMST) members may be
                 repositioned at medical facilities to advise on decontamination
                 procedures and treatment.

                 (7)     Most patients may only need limited treatment (depending
                 upon their exposure), but there may be a large number of patients
                 who will require extended in-patient, long-term treatment
                 including intensive care.

                 b.      Decontamination. Victims may arrive at hospitals without
             benefit of decontamination and will expect to be treated immediately.
             This will serve to spread the incident agent and potentially force the
             emergency room and/or hospital to shut down.

                 (1)    As a part of their plan for these events, hospitals and other
                 medical facilities should have decontamination procedures,
                 equipment, and trained personnel to initiate patient
                 decontamination for large numbers of patients at their facilities.

                 (2)    Hospitals cannot count on local hazardous materials
                 (HAZMAT) teams to respond and assist with patient
                 decontamination during an NBC event.

                 c.       Antidotes. Due to the agents available and the number of
             potential victims, large caches of atropine, 2-pam, and other antidotes
             appropriate to the event will be necessary.




11/ 05/ 10                                                                            5-2
                                                                                       City of Seattle
                                                                      Seattle Fire Department (SFD)
                                                          Metropolitan Medical Strike Team (MMST)
                           (1)     As a part of their plan for these events, hospitals and other
                           medical facilities will need to have procedures established for
                           stockpiling sufficient quantities of the appropriate antidotes to last
                           for the first 60 minutes of an event.

                           (2)     Ultimately, there will be a coordination effort with local
                           officials to distribute additional antidotes to facilities as necessary.
                           This will, in most cases, be by local jurisdiction transportation
                           from central distribution points.

                  2.       Emergency Care Clinics/Physicians Offices/Group Practices

             a.        Large Numbers of ‘‘Walk-Ins.’’ Many victims may self-refer to their
                       private physicians offices or health-care providers, e.g., walk-in clinics.

                           (1)     Non-hospital facilities need to have a plan for recognizing
                           unusual cases, providing medical preliminary intervention, and
                           determining which patients will require admission and transport to
                           a hospital. Once these unusual circumstances are recognized, they
                           must be reported to the local 911 center.

                           (2)      Pre-arranged transfer agreements with designated hospitals
                           and private ambulance transport companies should be in place to
                           facilitate patient transfer.

              b.       Decontamination Issues.           ‗‗Walk- ins‘‘ will not have been
                       decontaminated.

                           (1)     These patients should be quarantined in a section of the
                           facility where they can be decontaminated, receive medical
                           intervention, and be triaged for further transfer to local hospitals.

                           (2)    Plans should be in place to decontaminate the facility or
                           any segments of the facility that may have been contaminated.

             c.        Pharmacology Necessary. Non-hospital facilities need to have a plan
                       for acquiring indicated antidotes for administration for the first 60
                       minutes of an event. Ultimately, there will be a coordination effort
                       with local officials to distribute additional antidotes to facilities as
                       necessary.    This will, in most cases, be by local jurisdiction
                       transportation from central distribution points.

             d.        Further Transport to Hos pitals. Health care providers must be able
                       to determine which victims can be treated and released, which will
                       require more extensive care, and which must be further transported to
                       local hospitals.


11/ 05/ 10                                                                                        5-3
                                                                                        City of Seattle
                                                                       Seattle Fire Department (SFD)
                                                           Metropolitan Medical Strike Team (MMST)
                   3.       Public Facilities

                        a. Due to the potential for large numbers of victims who will need
                        only overnight observation and/or limited drug administration, it may
                        be necessary to open medical casualty collection centers for these
                        victims. Plans should be in place to identify such sites, stock the sites,
                        and provide medical professional personnel for the sites.

                        b. Current disaster shelter facilities should be considered first.
                        Secondary facilities may include large auditoriums, conference centers,
                        and other large-space facilities.

                        c. In the event that the agent is a vesicant, signs and symptoms may
                        not begin to surface for several hours but in severe cases will require
                        long-term intensive care. In these scenarios, patients may have to be
                        transported to Federal medical treatment centers and/or community
                        medical facilities in other locales.


             B.    Transportation

                  Due to the potential number of victims in an NBC incident, all available
              means of transportation will be necessary.

                   1.       Emergency Units.    All available Seattle Fire Department
                  emergency units will be needed for emergency transport to area medical
                  facilities.

                        a. Advanced life support (ALS) is necessary for serious to critical
                        patients and emergency responders.

                        b. Basic life support (BLS) is necessary for less than serious victims
                        who will need transportation.

                   2.    Private Providers. These units can be utilized for transport
                  between hospitals or from the incident scene.

                   3.     Other Transportation Mediums. The transportation listed below
                  should be considered in extreme cases where there are large numbers of
                  victims and conventional transportation efforts have been overwhelmed.
                  However, it must be recognized that emergency responders will need to be
                  assigned to these vehicles.

                   a.     Buses

                   b.     Cabs


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                                                                                     City of Seattle
                                                                    Seattle Fire Department (SFD)
                                                        Metropolitan Medical Strike Team (MMST)


                    c.   National Guard Assets (including trained medical professionals)

                    d.   Department of Defense (DoD) local assets (special hospital buses,
                         additional ambulances)

             C.     Fire Departme nts

                    1.      Fire Department 911 centers need to keep a fax listing of all
                   hospitals or equivalent medical facilities (where victims are likely to be
                   transported or may self- refer) for the purpose of rapid information
                   exchange.

                   a.    Hospitals

                   b.    Clinics

                   c.    Health  Maintenance       Offices/Preferred        Provider       Offices
                         (HMOs/PPOs)

                   d.    Private Physicians

              2.   Fire Departments should regularly review medical facility plans and
                   coordinate with these facilities to exercise their plans.




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                                                        Metropolitan Medical Strike Team (MMST)
                                     PART II: PUB LIC HEALTH


I.           CONCEPT

             A.    General

                    Public Health organizations at the local, State, and Federal levels have
              differing capacities to deal with disaster response. Most health departments
              have the capacity to investigate communicable disease outbreaks, to conduct
              surveillance programs, and to conduct environmental programs of varying
              types. Many do not have emergency response capabilities and do not have staff
              available nights, weekends, or holidays. In those cases, another provider must
              accomplish the functions described, or the capacity of the Public Health
              organization must be enhanced.

             B.    Support Between Levels

                    Existing consultation flows should be reinforced, rather than replaced or
              duplicated, to the degree possible. A physician seeing an unusual case (or
              cluster of cases) will normally ask advice of a community specialist. For
              example, an infectious disease consultant might call poison control or even
              Centers for Disease Control (CDC) depending upon the nature of the case. By
              providing training to those normally consulted, the likelihood that cases will be
              correctly identified as being sentinel cases of an event will be enhanced. In
              addition, issues of credible threat can be addressed by providing sensitive
              information to as few persons as possible, such as CDC staff, and routing
              inquiries quickly to that level. Index of suspicion is crucial to an early
              identification of the presence of a biological event. It is unlikely that sufficient
              training and warning can be provided to the typical front line physician to raise
              that index. Rather, it will be the accumulation of data at a higher level with
              prompt response and alert to lower levels that will provide the best opportunity
              for early intervention.

II.          ACTIVATION

             A.    EMS System

                   1.      Typically in response to a catastrophic event such as explosion,
                  accident, or sudden mass casualty situation.

                   2.    Decision to activate made by Incident Commander. Decision may
                  be prompted by dispatch.

                   3.     See Operations Section for discussion of Emergency Medical
                  Services (EMS) handling of overt events.



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             B.   Private Medical Provider

                   1.     Typically occurs when a large number of patients are seen who
                  have non-typical presentation, findings, or progress.

                  2.    Decision to activate is made by Public Health, EMS dispatch, or
                  MMST consultant, depending upon whom the provider notifies.

                   3.      Discussion.       The time of day/weekend/holiday will greatly
                  influence the segment of the private medical community to be affected.
                  During regular office hours, most ill persons will go straight to their
                  doctors‘ offices but may call and be referred to the Emergency Room (ER)
                  or choose to go to the nearest source of care, which may be an ―urgent
                  care‖ type of facility, depending upon symptoms. During nights, holidays,
                  and weekends, an affected person may call their physician for advice but
                  will more likely be referred to the ER if symptoms warrant. The daytime
                  scenario is most problematic in identifying an event but provides the
                  greatest opportunity to investigate and respond to it. One or more
                  physicians will have to develop a suspicion and call for advice. Since most
                  of the diseases of concern are reportable and most likely require telephonic
                  reporting for timeliness, the Public Health Department at the local and/or
                  State level is the most appropriate contact point. Since the CDC are often
                  called by physicians with unusual situations, a pathway from CDC to the
                  health department and to the MMST should be established. The ER
                  scenario is most helpful, for identification of an event, since a cluster of
                  cases is more likely. Responding to the event is more problematic, since
                  health departments are typically closed, and consultants are on call instead
                  of in the office. In the case where local Public Health authorities cannot be
                  reached, the CDC emergency number, (404) 488-7100, should be called.
                  CDC would initiate activation of the team, as well as State and local Public
                  Health response.

             C.   Public Health

                   1.     Typically occurs when routine evaluation of surveillance data
                  shows unlikely event or when call from a member of the public indicates
                  presence of event.

                  2.      Decision to activate is made by Public Health.

                   3.      Discussion. Public Health agencies at various levels receive direct
                  reports from physicians, hospitals, and labs regarding infectious diseases.
                  In some cases telephonic reports are required for certain diseases.
                  Otherwise, reporting is typically very slow. Health departments may
                  investigate all cases of certain diseases and only tabulate others. Reporting
                  is often complicated by labs reporting to the State level with physician, but


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                  not patient, address. Many of these reports are never referred to a local
                  department. The evaluation of patterns may not be timely. Calls from the
                  public are usually given some scrutiny; however, with most health
                  departments not being open nights, weekends, and holidays, a citizen report
                  may not be addressed in a timely fashion. When the data point to an
                  unusual situation, most health departments would respond promptly and
                  might call for State support. Access to the team for consultation during
                  these periods would most likely require the public to have enough
                  suspicion to call an ER, 911, or some other response entity for advice. This
                  entity, through pathways described above, could refer the matter to the
                  team. The availability of the MMST for this purpose would have to be
                  made known through the training programs, public announcements,
                  memoranda, and letters.

             D.   Law Enforce ment

                   1.      Typically would occur based upon an identified threat prior to an
                  event.

                   2.      Decision to activate would typically be made by the police
                  authority concerned, possibly in consultation with the team commander.

                   3.      Discussion. Unlikely to be frequently used because of restricted
                  nature of intelligence information. The identification of a credible threat
                  will most likely result in some notification of the communities targeted.
                  Having that information flow to the team may be important, as might
                  having it flow to providers who may be able to more quickly identify the
                  presence of an event, particularly a covert event. Law enforcement
                  (Federal, State, or local) should make the MMST Director aware of
                  credible threat situations. (See Team Alerting/Notification Chapter.) The
                  MMST might be mobilized to stand by in certain scenarios. In some of
                  those situations, Public Health, and in some cases even selected local
                  providers such as ER staff, might be selectively notified as well.




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III.         ACTIONS

             A.    Advisory

              1. Non-Events. Many possible incidents will not require extensive response
                 but rather will be routine situations with atypical presentations. The Public
                 Health responsibility will be to identify the nature of the situation and advise
                 on appropriate actions.

              2. Non-Response Events. Certain events may be resolved by prompt action
                 by another agency, without activation of Public Health resources. The
                 Public Health responsibility will be to ensure the matter will be addressed
                 by the appropriate agency, with advice as needed.

              3. Response Events. Provide recommendations as to the level and type of
                 response needed by Public Health Staff and provide medical and
                 epidemiological advice to responding agencies.

             B.    Analytical

              1. Epidemiological Support. Provide evaluation of illness, including case
                 definitions if appropriate, pattern of spread, locus of agent, etc.

              2. Assessment. Assist in determining probable areas of contamination,
                 populations at risk, and areas needing evacuation.

              3. Medical Intelligence. Through contacts with hospitals, ERs, urgent care
                 centers, private physician‘s offices, schools, etc., investigate the presence of
                 and/or spread of illness in the community.

             C.    Inte rventional

              1. Provide factsheets, treatment recommendations to medical community.

              2. Assist in the acquisition and distribution of pharmaceuticals and other
                 medical items to providers.

              3. Establish, as appropriate, treatment sites/medication distribution sites,
                 shelter first aid capabilities, specimen collection sites and/or teams, and
                 otherwise assist in the management of the medical support for the event.

              4. Coordinate health and safety matters with rescue units, fire, police, and
                 other responders. Provide surveillance for responders.

              5. Coordinate with private provider community to ensure resource availability,
                 patient distribution and out-of-system support are optimal.


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              6. Assist in patient decontamination and care as appropriate.

             D.     Remediation

              1. Assist in the decontamination/certification of safety for areas and structures
                 as appropriate.

              2. Assist in follow-on testing to ensure agent no longer poses a threat to the
                 community.

             E.     Community Follow-up

              1. Conduct, in conjunction with private medical community, surveillance of
                 those affected for sequelae.

              2. Conduct educational, supportive, and other programs to mitigate the long-
                 term psychological impact on the community.

              3. Evaluate food, water supplies, etc., for safety.

IV.          RESOURCES

             A.     Testing/Diagnostic Support

              Effective diagnostic support for an event will of necessity require the placement
              of testing capabilities with the clinical providers. The decision to prestock
              diagnostic testing materials designed for agents of concern will depend upon the
              cost, ease of use, specificity, and other factors related to the test, as well as the
              level of risk identified for the agent and the community. When not prestocked,
              plans for rapid deployment of capabilities must be made. Environmental testing
              will require protected staff, limiting its availability. The use of environmental
              testing materials may be a Public Health, Fire and Rescue, HAZMAT, Police, or
              MMST responsibility, depending upon the community, risk and other resources.

              1. Chemical agents- environment. Includes military test tapes M8, M9, test
                 kits M, Draeger tubes, and similar air testing devices.


              2. Chemical agents-clinical. Includes cholinesterase, other tests.

              3. Biological agents-environmental.       Includes swab tests with cultures, air
                 sampling devices.

              4. Biological agents-clinical. Includes elisa, rapid antigen tests, etc.



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              5. Radiological testing/monitoring equipment.

             B.    Analytical Support

                    Normal Public Health practice provides for the reporting of diseases and
              the analysis of disease patterns for outbreaks. Virtually all agents of concern
              fall under mandatory reporting, usually by telephone. For effective and timely
              analysis, tools for statistical and geographical analysis must be provided that
              would allow rapid identification of clusters, geographical dispersion, and other
              factors that would help determine the limits of the operation.

              1. Surveillance Systems. The systems must provide for the reporting to
                 multiple agencies (jurisdictions) with consolidation of data so that
                 widespread early identification of unusual disease patterns can be identified.
                 Influenza sentinel physician programs are a model.

              2. Epidemiological Analysis Packages. Identification of an event based upon
                 surveillance data will be problematic. Because the early symptoms of
                 several agents resemble influenza and other common community illnesses,
                 and those community illnesses have a wide range of impact, it is likely that
                 even with good reporting an event may not be detected in a timely way.
                 Routine statistical analysis with ‗‗triggers‘‘ (such as exponentially smoothed
                 estimates of baseline) may make early detection more likely.

              3. Geo/Mapping Support. The classic epidemiological study considered
                 place of work as well as place of residence in analyzing data for the source
                 of disease. In complicated urban areas like the Washington, DC, metro area,
                 analysis of patterns based upon several factors may be needed to identify the
                 source of an outbreak. Biological contamination of Metro, for instance,
                 might produce a sporadic pattern of disease that would be extremely
                 difficult to localize.

             C.    Cons ultative Support

                    Physicians in particular are likely to rely on their regular sources of
              consultation when faced with an unknown event. These sources typically
              include specialists on staff at the local hospital, particularly infectious disease
              specialists, and might include such outside sources as Poison Control, the local
              Health Department, and direct calls to CDC. Developing a new source of
              information outside these regularly used groups may not be useful.

              1. Toxicology. Calls to Poison Control, National Institute of Occupational
                 Safety and Health (NIOSH), toxicologists at the State Health Department or
                 a major university are most likely. The emergency room is most likely to
                 originate a call, since chemical agents are more likely to produce an acute
                 toxic state.


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              2. Infectious Disease. Local referral sources will be most commonly used.
                 Since many infectious disease physicians will not have current experience
                 with these agents, the diagnosis may be initially missed if training is not
                 provided to increase the index of suspicion for them.

              3. Epidemiological/Statistical/Mapping. State epidemiologists need to
                 become involved early in any event. Regulations for disease reporting and
                 control usually require such consultation. While many jurisdictions have
                 internal capabilities for epidemiological study, State- level assets are usually
                 well trained and equipped and have ready access to CDC resources.

             D.    Infrastructure

                   Public Health agencies are not typically staffed for 24-hour operations or
              equipped for emergency response. Providing for availability of on-call staff
              must be considered, as well as the means of utilizing the resources that can be
              made available.

              1. Transportation. Without emergency response vehicles, Public Health staff
                 will be essentially unavailable at the scene. Where environmental testing,
                 clinical surveys, or other functions are required, support of other agencies
                 may be required.

              2. Communications. Where Public Health resources are to be committed in
                 real time, communications capabilities to the level of other responders must
                 be provided.

              3. Personal Protective Equipment. Other than routine infection control
                 items, Public Health agencies are not typically provided with personnel
                 protection equipment (PPE). This would not normally be a limitation,
                 unless direct patient care is to be provided to contaminated patients or
                 sampling is required in contaminated areas.


V.           TRAINING

      At a minimum, staffs at all levels need to have awareness training. Basic concepts
      of how the community has planned to respond to various situations should be
      presented as well.

             A.    Health Departme nt Staff

                   Unless an emergency response function is planned, additional training
              would focus on ―train the trainer‖ programs so that the private medical
              community could be trained and on internal processes to support the analysis
              and consultation described above. If emergency response is contemplated,
              HAZMAT type training would need to be provided to responders, as well as

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              training on the use of whatever testing, diagnostic, or other resources to be made
              available. Patient care training would be as for the private physicians.

             B.    Private Physicians

                   Sufficient training to provide an index of suspicion for agents of concern,
              diagnostic steps to undertake if one is suspected, and treatment guidelines as
              appropriate. Information on sources of consultation should also be provided.
              Office and staff protection should be considered, depending upon the risks
              expected in the community.

             C.    Emergency Room Staffs

                   Training as for physicians, with additional training on protection of ER
              and staff from contamination, on triage of mass casualties, and on the
              decontamination of mass casualties.

             D.    Rescue Units

                    Handling of mass casualty situations with contaminated patients,
              particularly with rescue units without adequate personal protective equipment.

             E.    Community Agencies

                    Red Cross and other agencies providing shelter, medical, or other services
              need appropriate training for the protection of facility and staff, as well as that
              described for physicians, ER staff, and rescue units when dictated by service
              plans.

VI.          STAFFING

             A.    Physicians

                    Overall management of the Public Health response would typically be
              managed by a physician certified in public health/preventive medicine. The
              number of physicians needed would depend upon the response plan and patient
              care needs.

             B.    Public Health Nurses

                    Public Health Nurses (PHNs) would typically be involved in contact
              tracing and interviewing, including field visits, in investigating o utbreaks. The
              capacity for this type of investigation depends upon the staffing and experience
              of the Public Health agency involved. PHNs would in many cases be involved
              in the delivery of health care services in clinics, shelters, or the home. These
              services would be under the direction of Health Department physicians, or in the


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                                                                    Seattle Fire Department (SFD)
                                                        Metropolitan Medical Strike Team (MMST)
              case of a Health Department-operated home health agency, in accordance with
              orders from the patient‘s physician and might include everything from
              immunizations and medication administration to specimen collection and
              wound care. In either case, proper planning would allow effective PHN support
              to a range of scenarios.

             C.    Environmental Health Specialists

                    Often called Sanitarians, these individuals normally operate a range of
              programs that includes food safety (restaurant inspections and food-borne
              outbreak investigations), vector control, safe drinking water, sewage disposal,
              air pollution, and general environmental hazard investigations. The direct
              application of these skills to consequence management would require training
              and equipping, particularly if field operations in hazardous areas would be
              envisioned.

             D.    Epidemiologists

                   The skills necessary for the evaluation of disease patterns may be found in
              any of the above specialties. Specialists in epidemiology normally have a wider
              range of tools that can be applied to an event and are often made available by
              the State epidemiologist to assist in local outbreaks of disease. Basic skills
              would need to be present at any Health Department level tasked with
              surveillance and analysis functions.




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                                                                                     City of Seattle
                                                                    Seattle Fire Department (SFD)
                                                        Metropolitan Medical Strike Team (MMST)
                       METROPOLITAN MEDICAL STRIKE TEAM

                                LAW ENFORCEMENT FUNCTION


I.           OVERVIEW

             A. General

                The local law enforcement function is primarily that of protecting life and
                property through containment, communication and control of the incident.
                Local agency members will be among the first responders to any actual or
                suspected nuclear, biological, or chemical (NBC) incident. The safety of the
                law enforcement first responders is vital to the successful handling of these
                events. This section provides an overview of the law enforcement function as
                it relates to an NBC incident. More detailed information may be found in
                Team Operations, Section 3.

                It is recognized that all law enforcement functions shall be performed in
                accordance with applicable local, state, and federal laws, within the policies
                and procedures of the law enforcement agency, and within the limitations of
                available personal protective equipment. Due to the unique tactical
                considerations of an NBC incident, there may be times when the local law
                enforcement agency may be unable to perform particular law enforcement
                functions without considerable assistance from other resources such as the
                federal government.

             B. MMST Law Enforce ment Personnel

                The MMST has two law enforcement personnel assigned as team members, a
                Law Enforcement Liaison and an Intelligence Information Specialist. The law
                enforcement role of these personnel on the MMST is to provide coordination
                with the primary law enforcement agency during an NBC incident, participate
                in training in preparation for handling these incidents, and to coordinate and
                assist with the security and logistical support of the team.

             C. Local Law Enforcement (non-MMST)

                The primary functions of the local law enforcement agency are to control in-
                progress crime, restore law and order, ensure safe access for emergency
                responders, ensure that emergency responders can perform their duties
                without interference or obstruction, and take measures to prevent sub sequent
                attacks targeting emergency responders. Additionally, the agency may be
                called upon to preserve and collect evidence and conduct a criminal
                investigation.




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II.          RESPONSE PHASE GUIDELINES

             In addition to the importance of early recognition of the e vent as an NBC
             incident, all emergency first responders (including non-law enforcement
             personnel) must maintain a high level of awareness for the presence of secondary
             devices and the possibility that the incident is an intentional act with the
             perpetrator still on the scene. The incident could be a crime in-progress and the
             perpetrator may have additional devices and weapons, may have taken hostages,
             or may be barricaded, therefore presenting a continuing threat to first responders.
             On the other hand, it is possible the perpetrator may be one of the victims of the
             NBC agent.

             It is recognized that the MMST is primarily a hazardous materials/medical
             response team and not a tactical response team for in-progress crimes. Law
             enforcement has responsibility for in-progress crimes and will respond within the
             limits of the law and in accordance to the agency‘s operational policies and
             procedures. Law enforcement personnel will not be required to work in known
             contaminated areas without the proper personal protective equipment.

             At an NBC incident, in the absence of a clear indication of an accidental cause, it
             must be assumed that an act of terrorism has occurred until proven otherwise. An
             NBC incident may be an intentional criminal act; therefore the site of the incident
             mandates a crime scene designation and evidence preservation. All emergency
             responders must be mindful of the crime scene and evidence preservation while at
             the same time neutralizing potentially large contaminated areas and performing
             rescue operations.


      A.        MMST Law Enforce ment Personnel

             It is recognized that all law enforcement functions shall be performed in
             accordance with the applicable local, state and federal laws, within the policies
             and procedures of the law enforcement agency, and within the limitations of
             available personal protective equipment.

             When appropriate, the functions of the law enforcement members on the MMST
             (the Law Enforcement Liaison and Intelligence Information Specialist) include:

                   Gather and disseminate intelligence information, as appropriate
                   Coordinate with the local FBI office
                   Assist and coordinate with the primary law enforcement agency as
                    appropriate, regarding: MMST and scene security, traffic and crowd
                    control, evidence preservation and criminal investigation




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             B. Non-MMST Law Enforcement Personnel
                The use of additional law enforcement resources may be required at an NBC
                incident, which could include:

                    Control of in-progress crimes
                    Containment of the incident
                    Establish safe access to the scene
                    Restore law and order
                    Apprehension of the suspect(s)
                    Hostage negotiations
                    Traffic and crowd control
                    Tactical operations
                    MMST security
                    Scene security
                    Access control at local hospitals and emergency rooms
                    Responsibility for bombs and explosive devices
                    Search for secondary devices
                    Render safe any found devices, whether explosive or mechanical
                     dissemination type
                    Crime scene investigation
                    Evidence gathering, handling, and preservation
                    Coordination of the disposition of the deceased victims including decon,
                     evidence, and movement issues
                    Coordinate and assist with state and federal enforcement agencies

III.         SCENE OPERATIONS

                1.      At an NBC incident, the Incident command System will be utilized
                2.      Notify the local FBI office as soon as possible in order to access
                        federal resources
                3.      Establish a secure perimeter
                4.      The Federal Bureau of Investigation has full authority (Presidential
                        Decision Directive #39) over NBC terrorist events and will operate in
                        a unified command structure with the Incident Commander during the
                        incident. Primary control of the incident will eventually shift to the
                        FBI Special Agent In Charge (SAC), and at that time the local
                        responders will operate in support of the FBI.
                5.      Communications systems may become overloaded.               Plan for
                        alternative systems.
                6.      Recognize that there may be multiple crime scenes.

IV. INTELLIGENCE GATHERING AND DISSEMINATION

        The gathering and dissemination of intelligence information by Seattle Police
        Department personnel shall be performed in accordance with the mandates with


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         the City Of Seattle Ordinance #108333, ―Collection of Information for Law
         Enforcement Purposes.‖

         A.            MMST Coordination

                        1.The MMST Law Enforcement Liaison shall serve as the primary liaison
                              between the MMST and the Federal Bureau of Investigation (FBI)
                              regarding the gathering and dissemination of intelligence
                              information.

                        2.The MMST Law Enforcement Liaison is responsible for the collection
                              and dissemination of intelligence regarding any NBC or terrorist
                              incident in the region. These efforts may be coordinated with other
                              MMST sections, outside agencies, or established Emergency
                              operations Centers (EOC).

             B.         FBI Response

                        1.     A Presidential Directive and Congressional legislation has
                               designated the FBI as the Lead Federal Agency (LFA) in any
                               terrorist incident. The gathering of intelligence and the
                               investigation of these types of incidents are their responsibilities.
                               The FBI has response plans for terrorist incidents. An unclassified
                               version of their incident response plan is attached as Appendix A.

                        2.     The local FBI field office will provide an initial incident response.
                               They will determine the need for additional resources and activate
                               the Federal response, as necessary.

                        3.     Once an NBC incident has been verified, a response team from
                               FBI Headquarters (FBIHQ) in Washington, DC, may respond to
                               the incident.

V.           TEAM CASUALTY

             Team member‘s casualties associated with an NBC incident will be dealt with in
             accordance with the policies and procedures of the member‘s agency.

VI.          TRAINING AND EQUIPMENT

             It is imperative that first responders be properly trained and equipped for dealing
             with NBC incidents.

                  1.      Law enforcement personnel will enter known contaminated areas only
                          when wearing the proper personal protective equipment (PPE).
                  2.      Law enforcement personnel equipped with PPE will be trained in the
                          proper use of the equipment.

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                3.    All MMST law enforcement personnel will be trained in the recognition
                      of NBC agents and situations, and will be trained in the Incident
                      Command System.

VII.         EVIDENCE PRESERVATION AND COLLECTION

             It is important to remember that an NBC incident may be an intentional act and
             until proven otherwise, it will be assumed an act of terrorism has occurred. The
             site of an NBC incident shall be treated as a crime scene and all evidence will be
             preserved.

                1.    The preservation of life shall take priority over the preservation of
                      evidence at all times.
                2.    All evidence collection activities shall be coordinated with the primary
                      law enforcement agency.
                3.    All first responders should remain observant as they may be required to
                      record their observations of the crime scene for eventual use in the
                      prosecution of the perpetrator.
                4.    The primary law enforcement agency handling the incident may be
                      required to coordinate the handling and collection of clothing and other
                      items recovered off site, such as at hospitals, other treatment facilities, or
                      morgues, if of evidentiary value.

VIII. EMERGENCY OPERATIONS CENTER

                1.    The local law enforcement agency will coordinate with the local
                      Emergency Operations Center (EOC) regarding information and support
                      of the MMST law enforcement mission. In the City of Seattle, this will
                      be accomplished through the Seattle Police Operations Center (SPOC)
                      when activated.
                2.    The local law enforcement agency will abide by their agency‘s
                      procedures for an EOC activation.
                3.    In the City of Seattle, the Seattle Disaster Response Plan will guide EOC
                      actions.




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                      APPENDIX A: FBI INCIDENT RESPONSE PLAN
                                         (unclassified version)


                              FED ERAL B UREAU OF INVES TIGATION

                                   CHEMICA L/BIOLOGICA L (C/B)
                                  INCIDENT CONTINGENCY PLA N

                                          (UNCLASSIFIED)

I.           INTRODUCTION

             The first priority of the plan is public safety and the preservation of life. In a
             terrorist or other criminal-related C/B incident, the FBI will assume a central
             investigation and/or crisis management role, in association with local law
             enforcement authorities, to successfully resolve the incident. Concurrently, in a
             major incident, other specialized Federal entities from a variety of agencies and
             departments, will provide consequence management resources in support of state
             and local agencies. These resources are primarily designed to address health and
             safety issues, and include a wide variety of emergency support, including housing,
             food, and medical support.

             The plan is designed to marshal the appropriate Federal tactical, technical,
             scientific, and medical support to bolster the FBI‘s investigative and crisis
             management abilities and to augment state and local resources in addressing the
             threat inherent in a C/B incident. The contingency plan emphasizes coordination
             between all participants and is particularly concerned with the bridge between law
             enforcement activities and the management of the medical consequences of the
             crisis.

             If a terrorist or other criminal-related C/B incident should occur, the FBI will
             assume the lead Federal role to successfully resolve the incident and will closely
             coordinate efforts with appropriate local law enforcement agencies and other
             emergency authorities.

             Based on the specific details of an incident, at some time during the crisis, the
             responsibility for consequence management and public safety will be transferred
             from the FBI to the Federal Emergency Management Agency (FEMA) when the
             Attorney General (AG) determines that the priority law enforcement goals and
             objectives have been set or are outweighed by the consequence manage ment
             concerns. The FBI‘s C/B Incident Contingency Plan attempts to clarify and
             address this issue and provides guidance regarding the Federal management
             transition from the FBI to another Federal agency in this context.
             The probability of a major C/B incident occurring in the United States is difficult
             to quantify. However, the inevitability of a significant C/B incident is heightened
             by a number of factors, including the following:

              C/B agents are relatively inexpensive to produce.
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                                                                        Seattle Fire Department (SFD)
                                                            Metropolitan Medical Strike Team (MMST)

              Basic chemical precursors and biological production processes are relatively
               easy to acquire.

              The basic knowledge required to manufacture such substances is readily
               available.

              The impact on the public is intensified by the inability to quickly identify
               and/or contain the effects of such substances (particularly biological agents).

              Media coverage has increased the visibility and public knowledge of the use of
               C/B weapons, thus creating a more likely scenario for their use.

              The portability of small amounts of C/B agents (especially biological agents)
               makes them especially useful for clandestine purposes.

              The proliferation of C/B agent technology and development efforts worldwide
               has increased the stockpile of such weapons, thus elevating the potential for the
               acquisition or theft of the C/B weapons by terrorist groups.

             The public safety community must be prepared to address a chemical/biological
             event with regard to the evacuation, containment, neutralization, removal,
             cleanup, and disposal. Some possible scenarios may include:

              The sabotage of a hazardous chemical production or storage facility

              The hijacking or premeditated destruction of a tractor-trailer or railroad tanker
               containing hazardous materials

              Discovering an individual or a group of individuals involved in the
               manufacturing or possession of a C/B weapon

              The dispersal of a C/B agent among the civilian population, livestock, or
               agricultural industry

              The contamination of a municipal water or public food supply with a C/B
               agent

              The credible threat to accomplish one of the above


             A.      Graduated Response

                  In order to be effective, and for law enforcement to react safely to a C/B agent
                  incident, a graduated response is appropriate. Since the first priority is public
                  safety and the preservation of life, this graduated response by knowledgeable
                  public safety personnel would consist of the following:


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                                                                       Seattle Fire Department (SFD)
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                  1.    Assessment of the incident by trained responders in specialized clothing
                        and breathing apparatus

                  2.    Emergency deployment of technical personnel and resources to the
                        incident site

                  3.    Response and establishment of known management resources to a
                        command post area near the incident site


             B.        Jurisdictional Responsibilities

                  As each C/B incident will have its own specific identity, significant health and
                  safety issues may displace the precedence of law enforcement responsibilities.
                  At such a time, the lead role will be transferred to another agency with
                  consequence management responsibility for the incident.

                  Within the United States, the FBI has been assigned the lead law enforcement
                  role in responding to acts of C/B terrorism or other criminal-related C/B
                  incidents in which the FBI maintains jurisdiction. The FBI derives its
                  fundamental legal jurisdiction to deter, investigate, direct, organize, and
                  prepare for a C/B incident from an assortment of Federal statutes and
                  executive branch directives. Some of these include the following:

                  1.    Title 18, USC, Section 1365–Tampering with Consumer Products

                  2.    Title 18, USC, Sections 871-879–Extortion and Threats

                  3.    Title 18, USC, Sections 371-373–Conspiracy




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                                                                        Seattle Fire Department (SFD)
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                  4.    Title 18, USC, Sections 175-178–Biological Weapons Anti- Terrorism
                        (BWAT) Act

                  5.    Title 18, USC, Section 2332a–Weapons of Mass Destruction

                  Pursuant to this jurisdictional responsibility, the FBI will respond to all C/B
                  incidents by marshaling specialized FBI and other Federal resources to support
                  the Special Agent- in-Charge (SAIC) when faced with a potential C/B incident.
                  Recent legislation has made the use, attempt to use, or conspiracy to use a
                  weapon of mass destruction a Federal offense.

                  In addition, in 1990, the BWAT Act of 1989 was signed into law. This statute
                  makes it illegal to manufacture or possess biological agents for use as a
                  weapon or to assist a foreign country in the development of such a weapon. It
                  also contains extraterritorial provisions, as well as the ability to seize and
                  destroy biological weapons.


             C.        C/B Response Protocol

                  In a major release of a C/B agent with or without warning, the FBI will assume
                  the lead role in crisis management in the interest of public safety. The FBI will
                  continue to fulfill its law enforcement role as the situation dictates. However,
                  these efforts will be secondary to, and in support of, the consequence
                  management agency designated to coordinate Federal efforts in support of State
                  and local public entities.

                  Activation of a C/B Threat Assessment Plan should begin by taking the
                  following steps:

                  1.    Make contact with the FBI Field Office C/B Coordinator who will
                        immediately contact FBIHQ in Washington, DC.

                  2.    The FBI C/B Coordinator in Washington, DC, will contact the
                        appropriate FBIHQ Units having responsibility in a number of areas to
                        include tactical support, hostage negotiation, criminal investigative
                        analysis, aviation support, Bomb Technicians, FBI Laboratory, and other
                        specialized resources within the FBI.




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                                                                                 Seattle Fire Department (SFD)
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                  3.    The FBI C/B Coordinator in Washington, DC, will contact other Federal
                        agencies having C/B support capabilities and include some of the
                        following:

a.   Department of Defense, C/B Defense Agency

b.   Department of Defense, U.S. Army Technical Escort

c.   Health and Human Services, USPHS

d.   EPA

e.   Department of Agriculture, Emergency Programs

f.   FEMA

g.   Secretary of Defense

h.   Health and Human Services, CDC

i.   Health and Human Services, Food and Drug Administration (FDA)


             D.        Possible Incident Scenarios

                  1.    A verbal or written threat only

                  2.    The confirmed presence of a C/B weapon (without dissemination of the
                        agent)

                  3.    The release of a C/B agent, resulting in limited death or injury, requiring
                        limited consequence management

                  4.    The release of a C/B agent (with or without prior warning), resulting in
                        substantial injury or death and requiring significant consequence
                        management efforts.




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                                                                      Seattle Fire Department (SFD)
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II.   FBI COMMAND POST STRUCTURE (The Joint Operations Center
Concept)

             The SAIC in charge of the FBI‘s response to a C/B incident will establish an on-
             scene FBI command post designed to effectively coordinate and direct FBI
             actions and the actions of other agencies in response to the crisis. As the lead
             Federal agency, it is the FBI‘s responsibility to recognize, understand and
             coordinate other Federal agencies that have a duty to respond to a C/B incident.
             The standard FBI command post will be modified and function as a Joint
             Operations Center (JOC) under the direction of the SAIC.

             The JOC will be structured to include both Federal and State agencies and to
             enhance interagency cooperation. This command post concept has been designed
             to reflect the FBI‘s responsibility and authority as the lead Federal agency during
             a terrorist or criminal-related C/B incident and to facilitate the FBI management
             of such a complex interagency operation.

             The JOC will be composed of four main groups: Command, Operations,
             Consequence Management, and Support. Some of these groups will contain other
             components to assist the group in fulfilling its responsibilities. The group and
             components are described as follows:

             A. Command Group (CG): This group will be composed of senior officials of
                the FBI, Department of Defense (DoD), USPHS, FEMA, and other Federal,
                State, and local agencies as selected by the FBI, to provide the SAIC with a
                means to quickly coordinate and reach decisions on interagency matters that
                affect the resolution of the incident. The FBI SAIC will determine
                representation of agencies at CG briefings and meetings.

                In addition, the SAIC will designate a single individual to act as the point of
                contact (POC) between the CG and the FBIHQ Strategic Intelligence
                Operations Center (SIOC). All incoming and outgoing requests for
                information must go through the POC. The POC is responsible for keeping
                the CG and the FBIHQ/SIOC apprised of the status of the incident. Any
                communication occurring outside this channel should be immediately reported
                to the POC in order for him/her to keep FBIHQ/SIOC and the CG advised.

             B. Ope rations Group: Depending on the crisis, some or all of these CG
                components within the FBI or appropriate Federal, State, or local public safety
                entity may be staffed and used to resolve the C/B crisis:

                1.    Intelligence Component:            Collects, processes analyzes and
                      disseminates current and valid intelligence data. Provides situational
                      briefings to the individuals/groups designated by the CG.




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                       2.    Investigative Component: Initiates and perpetuates the investigative
                             activity. Documents crisis response and develops, assigns, and ensures
                             completion of investigative leads.

                       3.    Tactical Component: Directs and coordinates all tactical personnel at
                             the crisis site. Makes recommendations and provides situational briefs
                             to the CG.

                       4.    Technical Component: Directs and coordinates all technical personnel
                             at the crisis site. Makes recommendations and provides situational
                             briefs to the CG.

                       5.    Surveillance Component: Directs and coordinates both ground and air
                             surveillance  units.      Determines feasible options,       makes
                             recommendations, and provides situational briefs to the CG.

                       6.    Negotiations Component: Directs and coordinates all negotiations
                             personnel at the crisis site. Develops appropriate negotiation options
                             and makes recommendations to the CG.

                    C. Consequence Management Group: This group will be established by and
                       under the direction of the FBI to manage the additional Federal, State, and
                       local assets that will respond to any incident that has the potential for
                       generating mass casualties or destruction.

                    D. Support Group: This group will be established by and under the direction of
                       the FBI. This group will contain representatives of organizations whose
                       primary task is to support crisis organizations represented in the Operations
                       Group and will be asked for personnel to staff various support components.
                       Some of these support components are logistics, legal, media, administrative,
                       and liaison.

III.   DEFINITIONS

                    One of the fundamental obstacles associated with the control and regulation of
                    C/B weapons and agents is the difficulty in defining what constitutes such a
                    weapon or agent. Due to the extensive civil uses of raw materials employed in the
                    production of these weapons, a practical definition of what constitutes a weapon
                    is crucial to enforcement efforts. The central factor in such a definition is the
                    issue of intent.

                    Additionally, to be utilized effectively as a weapon, C/B agents must be delivered
                    to the target. This requires some type of delivery system, usually designed to
                    minimize contact and exposure to the perpetrator(s). Such a delivery system may
                    include a vector, which is a living organism capable of transferring a biological


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                                                                      Seattle Fire Department (SFD)
                                                          Metropolitan Medical Strike Team (MMST)
             agent to a victim (such as mosquitoes, rats, etc.); an aerosol dispersal device; or
             an explosive charge designed to vaporize the substance.

             The following definitions have been adopted to describe the basic nature of C/B
             agents:

             A. Chemical Weapons

                Chemical weapons are defined as compounds that through their chemical
                properties produce lethal or damaging effects in humans, animals, plants, or
                materials. Chemical weapons exist as solids, liquids, or gas and are classified
                by their effects: nerve, blood, choking, or blister agents.

                Chemical agents are also generally divided into three broad classifications,
                sometimes referred to as lethal agents, incapacitating agents, and harassing
                agents. Lethal agents are designed to kill or severely injure. Incapacitating
                agents are designed to disable the victim for at least several hours. These
                substances include those previously mentioned: nerve, blood, choking, and
                blister agents. Harassing agents, which include police riot agents, are
                designed to force people to retreat. Depending on the circumstances and
                conditions, even harassing agents can result in serious medical complications.

                Nerve agents, according to the World Health Organization, such as tabun
                (GA), sarin (GB), or nerve agent persistent chemical (VX), may be absorbed
                through the skin or respiratory tract. Exposure to nerve agents causes a
                disruption of nerve impulse transmissions and in sufficient quantities may
                cause almost instant death. Therefore, full protective clothing and a
                protective-breathing mask is required to ensure safety. The substances are
                stored as liquids and are usually disseminated as aerosols by means of an
                explosive charge. Aerosol dispensers also may circulate them.

                Blood agents, such as hydrogen cyanide (AC) and cyanogen chloride (CK),
                are generally colorless liquids widely used in commercial chemical
                manufacturing. Their danger lies in the fact that they interfere with cell
                respiration. These agents attack the body through the respiratory system and
                if inhaled in sufficient quantities act almost immediately. Cardiac arrest can
                occur almost instantly.

                Even though blood agents are fast acting, they dissipate quickly, and therefore
                are not as effective as nerve agents, particularly in a battlefield environment.
                A protective mask will provide short-term protection. However, these agents
                tend to saturate charcoal filters faster than most chemical warfare agents.
                They are disseminated by aerosol sprayer or vaporized by explosive charge.

                Choking agents cause damage to the tissues of the respiratory system and the
                eyes. In sufficient amounts, secondary infections can take place and in higher

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                                                                       Seattle Fire Department (SFD)
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                  concentrations death occurs. A protective mask provides sufficient protection,
                  provided that the atmosphere contains enough oxygen to support life.

                  Blister agents are tissue irritants. The most common blister agent is mustard
                  gas. This substance is a liquid with the consistency of motor oil. Significant
                  exposure will result in death between the second day and the fourth week. In
                  lesser amounts, exposure to blister agents causes symptoms similar to severe
                  burns and may result in secondary infections. Although generally not lethal
                  unless exposure is significant, inhalation or contact with the eyes results in
                  immediate searing pain. Therefore, full protective clothing and a protective-
                  breathing mask is required to ensure safety.

                  The lethality of chemical warfare agents depends on the concentration of the
                  agent and on the method of induction into the body.

             B.      Biological Weapons

                  Biological agents are generally divided into either replicating (infectious)
                  agents or nonreplicating (non-infecting or intoxicating) agents. Replicating
                  agents are pathogenic bacteria, viruses, or fungus. Nonreplicating agents are
                  produced from replicating agents, other living organisms, and plants and are
                  called ‗‗toxins.‘‘

                  Biological weapons are regarded as infectious agents or toxins, which are
                  pathogenetic to humans. These may include numerous naturally occurring
                  viruses, bacteria, or fungi previously known to science, as well as genetically
                  engineered organisms previously unknown. These substances possess the
                  common ability to kill or incapacitate large numbers of people. Biological
                  weapons are defined as any micro-organism, virus, infectious substance, or
                  toxin, capable of causing death, disease, or other biological malfunction in a
                  human, animal, plant, or other living organism. Toxins are poisonous
                  substances produced by a living organism, but in some cases can also be
                  synthetic.

                  The danger of biological weapons is amplified by the fact that exposure to the
                  agents would probably not be diagnosed until symptoms appeared.
                  Comprehensive quick field detection and identification methods do not
                  currently exist for these agents. Not only may an accurate diagnosis be
                  difficult to quickly accomplish, but the value of medical treatment for some
                  agents may be diminished once symptoms have developed. Personal
                  protection generally consists of immunization or the application of some other
                  post-incident medical treatment, such as the antibiotics. A chemical
                  protective mask also protects personnel from biological agents.

                  Viruses primarily cause diseases in humans. Transmission of these viruses in
                  a weapon system would most likely be accomplished by aerosol dissemination

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             or the use of a vector (a living organism capable of delivering a biological
             weapon to a victim, such as fever, headache, nausea, or vomiting, following
             an incubation period of a matter of days). These illnesses can be fatal if
             untreated.

             Bacterial agents can be produced in the laboratory or purchased from a
             number of medical research firms. Aerosol or natural dispersal such as food
             contamination would probably accomplish dissemination. Infections are
             introduced through the respiratory tract. An incubation period may last from
             one day to several weeks and the fatality rate for untreated cases may exceed
             80 percent. Water supplies are particularly susceptible to contamination by
             strains of certain bacteria. However, it is extremely difficult to contaminate
             most municipal water systems. The number of purification and filtering
             procedures and treatments built into municipal water systems would rid the
             water of any contamination. Private water supplies or water supplies that are
             not subjected to a rigorous purification process are at risk.

             Fungal infections usually are induced through the respiratory system by
             breathing infected spores. Fungal infections can be spread through the
             civilian or agricultural population, and would be extremely difficult to detect
             prior to the first casualty. At this time, there are no known applications of
             fungal infections, which would lend themselves to being used as a biological
             agent for a weapon.

             Toxins are defined as poisonous substances made by living organisms and can
             cause incapacitation or death quickly. Toxins can now be reproduced through
             new advances in biotechnology.




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                                   FED ERAL B UREAU OF INVES TIGATION

                                                NUCLEA R
                                       INCIDENT CONTINGENCY PLA N

                                               (UNCLASSIFIED)


     Within the United States, the FBI has been designated as the lead law enforcement
     agency in responding to threats or acts of terrorism, to include terrorist threats involving
     nuclear weapons or materials. The FBI derives its fundamental legal jurisdiction to deter,
     investigate, direct, organize and prepare for a nuclear terrorist incident from an
     assortment of Federal statutes and executive branc h directives. In order to facilitate the
     FBI‘s response to terrorist or criminal-related nuclear incidents occurring within the
     United States or its territories, the FBI‘s Nuclear/Biological/ Chemical Proliferation Unit,
     Domestic Terrorism/Counterterrorism Planning Section, National Security Division, FBI
     Headquarters (FBIHQ), has developed the Nuclear Incident Contingency Plan (NICP).
     The NICP marshals FBI and other specialized Federal resources to the incident.
     State/local resources, especially first responders, will play an important role in support of
     the FBI‘s Special Agent in Charge (SAC)/On Scene Commander (OSC) when faced with
     a nuclear incident.

     The NICP outlines the FBI‘s responsibility of notifying pertinent agencies and deploying
     the necessary technical resources to assist FBI field operations in investigating,
     containing and minimizing the consequences of the threat.

     This document, which provides a general overview of the FBI‘s NICP, is designed to be
     utilized as a basic resource only and should not be relied upon for precise answers to
     specific and complex questions and problems.

     *All nuclear threats and/or incidents should immediately be reported to the nearest
     FBI office.

I.   INTRODUCTION

                  The NICP is designed to provide the FBI with info rmation that will aid in the
                  thwarting and crisis management of a terrorist or criminal-related nuclear
                  incident. Although the United States has never been faced with a full-scale
                  nuclear terrorism incident, the magnitude of destruction from a nuclear yie ld or
                  the public terror which would result from even a credible threat of a radioactive
                  release among the populace, undoubtedly would appeal to certain criminal or
                  terrorist elements.

                  Of particular concern to U.S. law enforcement and intelligence agencies is the
                  attempt by several state sponsors of terrorism to acquire the knowledge and
                  technology necessary to establish an indigenous nuclear program capable of
                  producing Special Nuclear Material and nuclear weapons.

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                                                                       Seattle Fire Department (SFD)
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             Any type of nuclear or radiological device should be considered a weapon of
             mass destruction. Consequently, any attempt to purchase materials and
             technology associated with the production of such devices continues to threaten
             the United States and will be aggressively investigated and prosecuted.

             The complexity of a terrorist- or criminal- related nuclear incident requires that the
             FBI rely on the expertise of other Federal agencies, such as the DoD and the
             Department of Energy (DOE), to assist in the resolution of a crisis. Without the
             technical and scientific expertise of these agencies, it would be virtually
             impossible for the FBI to successfully resolve a nuclear crisis. The DOE provides
             experts trained to search and locate either a nuclear device or nuclear material, as
             well as personnel equipped to diagnose, disable, or limit the detonation of a
             nuclear device. The DoD provides personnel trained to disarm and dismantle an
             explosive device and those booby traps surrounding the device.

             In addition to the DoD and DOE, the FBI relies on Federal agencies such as the
             Nuclear Regulatory Commission (NRC), FEMA, USPHS, and the EPA if crisis
             management evolves into consequence management. The FBI also relies on State
             and local law enforcement, fire/rescue and emergency medical service agencies.
             Even with this unique alliance of agencies, the FBI has the tremendous
             investigative burden of locating the general vicinity of the nuclear device.

             In order to ensure that the FBI is able to efficiently manage not only FBI activity,
             but also the activities of the other involved agencies, the FBI developed the JOC
             concept. This concept represents a change in the method of coordinating the
             interagency approach to nuclear-related terrorism matters within the United
             States. The JOC consists of a standard FBI crisis command post that is enlarged
             in a unique fashion to better address the specialized and complex demands created
             by a nuclear terrorism incident.

             The FBI‘s NICP would be implemented immediately upon receipt of information
             relating to a credible nuclear terrorism threat or incident. This plan notifies the
             necessary FBI personnel and ensures that the management of the crisis is swiftly
             and competently initiated and implemented. In addition, the plan marshals
             specialized resources and personnel from the DOE and DoD, as well as other
             involved Federal agencies, who possess the specialized technical expertise to
             assist the FBI in resolving such an incident. Furthermore, all FBI field offices
             maintain site-specific nuclear contingency plans, which are regularly updated.
             A nuclear terrorism or criminal-related incident occurs when one or more of the
             following occur:

                The detonation of a nuclear device

                The theft of a nuclear device



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                      The illegal sale, illegal purchase, or theft of Special Nuclear Material,
                       Controlled Nuclear Material, By-Product Material or Source Material

                      The production and/or detonation of an Improvised Nuclear Device (IND)

                      The production and/or detonation of a Radiological Dispersal Device (RDD)

                      The sabotage of a nuclear facility or facility housing nuclear materials

                      The threat to accomplish any of the above

                   Although the practical likelihood of an act of nuclear terrorism occurring in the
                   near future remains low, the FBI is committed to confront and handle such an
                   event.

II.   FBI RESPONSIBILITIES

                   Pursuant to the FBI‘s responsibility to respond to terrorist- or criminal-related
                   nuclear incidents, the FBI maintains a measured tactical response capability to
                   respond to terrorist incidents nationwide. Upon the receipt of a credible nuclear
                   threat or the confirmed existence of a nuclear weapon, an IND, or an RDD, the
                   FBI is prepared to deploy a number of resources to the scene. The extent and
                   level of response depends on the circumstances of the incident.

                   FBIHQ will immediately notify the DOE Emergency Operations Center (EOC) of
                   the threat. The threat will be analyzed by the DOE threat credibility assessment
                   system. The DOE-managed assessment process is designed to assist the FBI in
                   assessing the credibility of a specific nuclear threat. It augments other FBI
                   investigative and intelligence information that is being gathered
                   concurrently. If the threat were deemed to be credible, the FBI‘s NICP would be
                   initiated and the FBI would do the following:

                      Establish a JOC composed of representatives from other Federal agencies,
                       State/local law enforcement agencies, and first-responder agencies as deemed
                       appropriate by the OSC. This action is designed to facilitate FBI response and
                       interagency coordination.

                      Within the JOC, establish command, operations, consequence management,
                       and support groups, all of which are designed to reinforce and enhance
                       interagency operations.

                      Direct on-site Federal response activities through the FBI OSC.

                      Coordinate all operational aspects of the incident.



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                Provide security, or other appropriate support, to DOE and DoD personnel as
                 necessary.

                Staff a headquarters level 24-hour command center and provide direct liaison
                 to DoD and DOE command centers as warranted.

             During any or all of the above listed actions, the FBI would request the assistance
             of DoD and DOE assets to deal with the crisis. These assets would be deployed
             to the scene as rapidly as possible.

             In particular, the DOE‘s Nuclear Emergency Search Team (NEST) and other
             specialized assets would be deployed to the scene of a nuclear crisis. NEST,
             which is one of many of the DOE‘s assets utilized in the response to a nuclear
             threat or incident, was designed by the DOE to conduct, direct, and coordinate
             search and recovery operations for nuclear materials, weapo ns or devices; to assist
             in the identification and deactivation of INDs and/or RDDs; and to render advice
             on radiation and damage probabilities in the event of the detonation of an IND.
             The NEST maintains this technical support capability in a 24-hour state of
             readiness in order to provide an immediate response to a nuclear emergency.

             State and local law enforcement agencies play an important role in immediate
             and graduated response capability. First responders safeguard lives and, if
             possible, contain the situation until arrival of additional Federal assets. Even after
             the arrival of Federal assets, e.g., FBI, DoD, DOE, NRC, and consequence
             management personnel, continued coordination with State and local law
             enforcement agencies will be vital.




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III.         FBI COMMAND POST STRUCTURE (The JOC Concept)

             The FBI field division‘s SAIC, or other designee as selected by the Director of the
             FBI, will establish a JOC. The JOC will include Federal, State, and local agencies
             to not only enhance interagency cooperation, but also capitalize on the resources
             accessible to each agency. The JOC concept has been designed to reflect the
             FBI‘s responsibility and authority as the lead Federal agency during a terrorist- or
             criminal-related nuclear incident and to facilitate the FBI‘s management of such a
             complex interagency operation. The JOC will be under the direction of the SAIC
             or designee who will function as the OSC.

             The JOC will be composed of four main groups: Command, Operations,
             Consequence Management and Support. Some of these groups will contain other
             components to assist the group in fulfilling its responsibilities. The groups and
             components are described as follows:

             A. CG: This group will be composed of senior officials of the FBI, DoD, DOE,
                NRC, USPHS, FEMA, and other Federal, State, and local agencies as selected
                by the FBI to provide the OSC with a means to quickly coordinate and reach
                decisions on interagency matters that affect the resolution of the incident.
                Representation of agencies at CG briefings and meetings will be determined
                by the FBI OSC.

             B. Ope rations Group: This group will be established by and under the direction
                of the FBI. This group will contain representatives of organizations that are
                directly involved in actions in and around the crisis site and whose actions are
                deemed critical to the successful resolution of the crisis.

             C. Ope rations Group Components: Depending on the crisis, some or all of
                these components may be staffed and used to resolve the crisis. Each
                organization represented in the Operations Group will provide a representative
                to each of these components.

                1.    Intelligence component
                2.    Investigative component
                3.    Tactical component
                4.    Technical component
                5.    Surveillance component
                6.    Negotiations component




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                   D. Consequence Management Group: This group will be established by and
                      initially under the direction of the FBI to manage the additional Federal, State,
                      and local assets that will respond to any incident that has the potential for
                      generating mass casualties or destruction.

                   E. Support Group: This group will be established by and under the direction of
                      the FBI. This group will contain representatives of organizations whose
                      primary task is to support members of the Operations Group. It is within this
                      group that most organizational variations occur. Often, the legal and media
                      components are assigned in direct support to the CG. The Support Group
                      supervises the following components:

                      1.    Media
                      2.    Legal
                      3.    Administrative
                      4.    Logistics
                      5.    Liaison

IV.   DEFINITIONS

                   A. By-Product Material: Any radioactive material (except Special Nuclear
                      Material) yielded in or made radioactive by exposure to radiation that is
                      incident to the production or use of Special Nuclear Material.

                   B. Consequence Management: The management of Federal, State, and local
                      assets which will respond to any incident that has the potential for generating
                      mass casualties or destruction. This includes appropriate planning and
                      response efforts in concert with law enforcement crisis management efforts.

                   C. IND: A device incorporating radioactive materials designed for the formation
                      of an explosive nuclear yield. Such devices may be fabricated in a completely
                      improvised manner or may result from the sabotage, seizure, theft, or loss of a
                      U.S. or foreign nuclear weapon.

                   D. JOC: The center established by and under the direction of the FBI at or near
                      the site of the event that serves as the nucleus for decision making,
                      coordination, and overall management of ongoing operations. The JOC is an
                      expansion of the on-scene FBI command post.




      11/ 05/ 10                                                                                    6-A-16
                                                                                     City of Seattle
                                                                    Seattle Fire Department (SFD)
                                                        Metropolitan Medical Strike Team (MMST)
             E. Nuclear Incident: Any situation involving lost, stolen, missing, or the
                unauthorized possession of Special Nuclear Material, Controlled Nuclear
                Material, By-Product Material, Source Material, nuclear weapons, or
                components thereof. Nuclear incidents also include the use of improvised
                nuclear devices, radioactive dispersal devices, or the threatened use of such
                items, as defined by the Atomic Energy Act (AEA) of 1954, as amended.

             F. Nuclear Weapon: A general name given to any weapon in which an
                explosion results from the energy released by reaction involving atomic
                nuclei, either by fission, fusion, or both. A nuclear weapon may be of U.S. or
                foreign manufacture.

             G. Radiation: High-energy particles or gamma rays that are emitted by an atom
                as the substance undergoes radioactive decay. Particles can be either charged
                alpha or beta particles, or neutral neutron or gamma rays.

             H. RDD: A device incorporating radioactive materials designed to be
                surrounded with conventional high explosives and detonated in order to
                scatter or otherwise contaminate an area with radioactive particles. An RDD
                is not designed to produce an explosive nuclear yield.

             I. SIOC: The FBIHQ command post, which coordinates actions among other
                headquarters- level Federal agencies.




11/ 05/ 10                                                                                  6-A-17
                                                                                      City of Seattle
                                                                     Seattle Fire Department (SFD)
                                                         Metropolitan Medical Strike Team (MMST)
                         METROPOLITAN MEDICAL STRIKE TEAM

                           PUB LIC INFORMATION - MEDIA RELATIONS


I.           PURPOSE

             Metropolitan Medical Strike Team (MMST) operations constitute extremely
                difficult and dangerous activities under radically abnormal conditions.
                Nuclear, biological, or chemical (NBC) events will result in significant media
                attention. The purpose of this section is to define the role of the media
                relations of the MMST and the parameters for information release in the event
                of an NBC terrorism event. MMST members are cautioned that in order to
                maintain consistency, all information releases should be authorized by the
                TFL.

             A. Media Relations

                    1.     Coordination with local PIOs. A basic tenant of the MMST is to
                           coordinate with, not take over from, local authorities.

                    2.     Maintain contact with MMST Task Force Leader. This is important
                           to ensure appropriate and accurate information flow.

                    3.     Develop incident/event information to be released. This is a critical
                           element of the PIO function.

                    4.     Establish a regular briefing schedule for information collection and
                           dissemination.

                    5.     Preplanning. PIO information management, local exercises, and
                           successful historical PIO actions.

                    6.     Ensure adequate personnel training on the subject of NBC events.


             B. Coordination with Local PIOs

                    1.     Once the MMST has been deployed to an event, the team PIO will
                           seek out the local PIO to ensure a coordinated media relations effort.

                           a.      Guidelines for information release/dissemination should be
                                   predeveloped as standard operating procedures.
                           b.      The team PIO will, in coordination with the MMST Task
                                   Force Leader, ascertain what agent(s) is involved, what
                                   actions have been taken, and what actions are being
                                   planned.


11/ 05/ 10                                                                                       7-1
                                                                                     City of Seattle
                                                                    Seattle Fire Department (SFD)
                                                        Metropolitan Medical Strike Team (MMST)
                         c.      Based upon the information in ‗‗a‘‘ above, the team PIO, in
                                 coordination with the MMST Task Force Leader and local
                                 jurisdiction PIO, will determine what information is
                                 appropriate to release to avoid panic, promote optimum
                                 community response, and support the team mission.

             C. Liaison with MMST Task Force Leader

                   1.    The Plans Section Chief will assume the role of PIO unless
                         otherwise designated by the TFL

                   2.    It is very important that the team PIO maintain a close working
                         relationship with the MMST Task Force Leader to ensure that the
                         appropriate information is disseminated, both in emergency and
                         non-emergency situations.

                   3.    Information release. Events of this type will result in significant
                         media attention. The general policy for the media is to establish an
                         active relationship with all facets of the media prior to, during, and
                         immediately after the event.

                   4.            During an event, coordinate with the local PIO to:

                         a.      Establish safe media conference areas distant from the
                                 incident command post,

                         b.      Establish regular briefings, and

                         c.      Develop information releases that support team activities.

                                    Medical facilities victims can report to

                                    Transportation avenues and other areas that are closed
                                     off

                                    Immediate first aid measures that can be taken

                                    Location of shelter facilities where evacuated personnel
                                     have been moved to

                   5.    After an event, release non-sensitive information about the event.

                              a. Basic information regarding the event:

                                    Where, what, why, how



11/ 05/ 10                                                                                      7-2
                                                                                       City of Seattle
                                                                      Seattle Fire Department (SFD)
                                                          Metropolitan Medical Strike Team (MMST)
                                      Units responding

                                      Number of casualties

                               b. Examples of types of information that should not be
                                  released:

                                      Names of fatalities

                                      Specific type/name of agent involved (until after
                                       incident is terminated)

                                      Dispersal method(s) used

                                      Specific law enforcement activities


             D. Preplanning

                    1.      Develop strategies for information packets and PIO information
                            management.

                    2.      Conduct exercises with media and local PIO to work out concerns
                            and remedies for the PIO role.

                    3.      Coordinate with Communications Section to establish phone, fax,
                            and radio linkages to appropriate outside agencies.


             E. Training

                    1.      The Plans Section Chief or designated PIO should attend all training
                            and related activities to ensure that he/she is competent to speak
                            about the issues inherent in NBC terrorist events.

                    2. Develop training outlines that can be utilized to train (overview)
                       local jurisdiction PIOs and media representatives.
II.          non-EMERGENCY ACTIVITIES

             In non-emergency periods between activation, it is essential that the U.S. Public
                 Health Service (USPHS) MMST PIO initiate fundamental media-related
                 public awareness activities. These activities consist of conducting briefings;
                 the development of press releases, media advisories, feature stories, and other
                 public information documents; and the cultivation of contacts with media
                 representatives.



11/ 05/ 10                                                                                        7-3
                                                                                         City of Seattle
                                                                        Seattle Fire Department (SFD)
                                                            Metropolitan Medical Strike Team (MMST)
             At the local level, organizations sponsoring an MMST should maintain regular
                communications with the media to publicize their local jurisdictio n’s specific
                capabilities.

             A. Feature articles highlighting activities and program accomplishments.
                   Articles should be suitable for local newspapers, national magazines, and
                   trade journals.

             B. In conjunction with USPHS, develop and distribute reference material
                   describing and promoting the Federal Response Plan (FRP) and the
                   MMST, including written and video productions.

                    1.      Written material should include pamphlets and booklets that
                            describe the MMST role in the FRP.

                    2.      Develop MMST program factsheets, backgrounders, and briefing
                            books detailing the program history, key talking points, and funding
                            issues during mobilization.

                    3.      Work with appropriate agencies, including the media, to develop a
                            public awareness of NBC incidents and aid in educating about the
                            potential for NBC incidents and the appropriate response actions.

                    4.      Provide factsheets that illustrate indicators of potential events:

                             Large numbers of casualties, dead wildlife

                             Unusual containers in odd locations

                             Unusual or unwarranted spraying activities

                             Unusual odors or spilled liquids

                             Vehicles (particularly trucks) in abnormal locations


III.         MEDIA MANAGEMENT SUGGESTIONS

             A. Inte rvie wing ‘‘Do’s’’:

                        Ask the reporter’s name. Use it in your response.

                        Use your full name. Nicknames are not appropriate.

                        Choose the site (if possible). Make sure you are comfortable with the
                         location of the interview. Consider what is in the background.


11/ 05/ 10                                                                                          7-4
                                                                              City of Seattle
                                                             Seattle Fire Department (SFD)
                                                 Metropolitan Medical Strike Team (MMST)


                Choose the time (if possible). If you would be more comfortable
                 waiting another 5 minutes, ask the reporter if that is okay.

                Be calm. Your demeanor and apparent control of the situation are
                 very important in establishing the tempo of evolving events.

                Tell the truth.

                Be cooperative. There is an answer to most questions. If you do not
                 know it now, let them know you will work diligently to determine the
                 facts needed.

                Be professional. Do not let your personal feelings about the media in
                 general, or this reporter, affect your response.

                Be patient. If the same questions are asked again, repeat your answer
                 without irritation.

                Take your time. If you make a mistake, indicate that you would like
                 to start over with your response.

                Use wraparound sentences. This means repeating the question with
                 your answer for a complete ‗‗soundbite.‘‘




11/ 05/ 10                                                                               7-5
                                                                                       City of Seattle
                                                                      Seattle Fire Department (SFD)
                                                          Metropolitan Medical Strike Team (MMST)
             B. Inte rvie wing ‘‘Don’ts’’:

                       Say ‘‘No comment.’’

                       Give your personal opinion. Stick to the facts.

                       Go off the record. Anything you say can and will be used against
                        you.

                       Lie.

                       Bluff. The truth will come out.

                       Be defensive. The media and their audience recognize a defensive
                        attitude and tend to believe you are hiding something.

                       Be afraid. Fear is debilitating and is not a characteristic you want to
                        portray.

                       Be evasive. Be up front on what you know about the situation and
                        what you plan to do to mitigate the incident.

                       Use jargon. The public is not familiar with much of the language
                        used by the MMST.

                       Confront.

                       Try to talk and command an incident at the same time.

                       Wear sunglasses.

                       Smoke.

                       Promise results or s peculate.

                       Respond to rumors.




11/ 05/ 10                                                                                        7-6
                                                                                      City of Seattle
                                                                     Seattle Fire Department (SFD)
                                                         Metropolitan Medical Strike Team (MMST)
                        METROPOLITAN MEDICAL STRIKE TEAM

                               EQUIPMENT CACHE REQUIREMENTS


i.           introduction

             A. The Metropolitan Medical Strike Team (MMST) operations constitute one of
                the most complex activities emergency responders may encounter. The
                organization and management of a comprehensive equipment cache must not
                only meet the needs of on-scene operations but also promote efficient
                packaging, handling, and transportation both to and from the incident location.
                Efficient packaging, handling, and transportation of cache equipment and
                supplies are fundamental to meeting the time constraints of response to
                nuclear, biological, or chemical (NBC) incidents. In order to minimize
                response time, all equipment and supplies should be prepackaged into a cache.

             B. All equipment and supplies that comprise the MMST cache should be
                identified and listed in the Equipment Appendix. The organization sponsoring
                an MMST assumes responsibility for the storage and maintenance of the
                cache. Computer-generated and maintained inventory databases should be
                used.

             C. The determination of the cache storage location is the responsibility of the
                sponsoring organization, and it should give consideration to accessibility for
                routine inventory and maintenance, as well as proximity to major highways.
                All supplies, tools, and equipment must be kept in a secure area. All
                equipment will be boxed, tagged, labeled, and kept ready for immediate
                deployment. A requisition system should be established for the immediate
                purchase of items with shelf life that cannot be stored with the cache.


II.          CACHE PACKING STANDARDS

             The following general standards are required for MMST caches:

             A. The cache is essentially divided into five separate elements. Color-coding
                will expedite the sorting of containers during mobilization and on-site
                activities. To ensure uniformity in marking containers, the following colors
                will be used to denote the various elements:




11/ 05/ 10                                                                                       8-1
                                                                                      City of Seattle
                                                                     Seattle Fire Department (SFD)
                                                         Metropolitan Medical Strike Team (MMST)
                    1.     PERSONAL PROTECTIVE EQUIPMENT (PPE)                              red

                    2.     MEDICAL                                                          blue

                    3.     DETECTION/SAMPLING                                               yellow

                    4.     LOGISTICS/COMMUNICATIONS                                         green

                    5.     DECON                                                            white

             B. The ability to rapidly identify and package supplies and equipment is
                necessary to efficiently deploy and track cache items. This process is
                facilitated by including the following information on each container:

                    1.     Inventory number of container

                    2.     Unit name

                    3.     Contents

                    4.     Color-code of the equipment category

             C. In order to ensure security and avoid unnecessary damage to cache items, all
                containers should meet the following requirements:

                    1.     Constructed of high-impact material

                    2.     Weatherproof

                    3.     Provided with handles or retractable handles

                    4.     Provided with stackable corners

                         5. Provided with fasteners to prevent accidental opening

                         6. Gross weight of container and contents should not exceed 150
                            pounds

                    7.     Easy to decontaminate


             D. The packaging of equipment into containers should be do ne not only for ease
                of handling during transport, but also with operational considerations in mind.

III.         CACHE MOVEMENT AND DEPLOYM ENT



11/ 05/ 10                                                                                         8-2
                                                                                      City of Seattle
                                                                     Seattle Fire Department (SFD)
                                                         Metropolitan Medical Strike Team (MMST)
             A. Supervisory personnel must plan for ground transportation requirements
                according to the cubic space and gross weight of the entire cache. Ground
                transportation during mobilization and while on site will require manual
                handling and loose loading of cache containers. Adhering to the container
                weight and size limitations will ensure overall manageability of the cache and
                is of paramount importance.

             B. The sponsoring organization is responsible for the assembly, management,
                and movement of the cache from its home jurisdiction to the staging area
                during mobilization. This requirement should be fully defined, preplanned,
                and exercised prior to any actual mobilization. The following issues should
                be addressed:

                    1.     Process for assembling and packing all cache tools, equipment, and
                           supplies (should the items not be maintained as a ‗‗stand-alone‘‘
                           cache).

                    2.     Process for identifying, procuring, and packaging short shelf life
                           items (i.e., batteries, fuels).

                    3.     Process for generating an inventory of all cache items.

                    4.     Compliance with appropriate shipping regulations.


IV.          EQUIPMENT CACHE ACCOUNTABILITY

             A. The MMST must rely on the availability and readiness of equipment to
                support on-scene operations. A comprehensive property accountability
                system is essential for ensuring that equipment readiness is maintained. A
                system for accountability must be developed before any mobilization to
                ensure cache readiness. Ongoing maintenance and exercise of the cache
                equipment must be assured for operational readiness between mobilizations.
                As such, there must be an organized system of equipment inventory,
                maintenance, and routine operation to ensure that the cache is ready for
                immediate response.

             B. The Logistics Specialist position has primary responsibility for property
                accountability and resource tracking during the mobilization, mission
                operation, and demobilization phases. This position tracks, distributes,
                maintains, and accounts for all equipment for the team.

             C. Post-mission inventory and status check procedures are extremely important
                for the subsequent readiness of the cache. All items must be inventoried,
                cleaned, overhauled, and checked for damage prior to return to storage. This
                information must be transferred to the inventory database.


11/ 05/ 10                                                                                       8-3
                                                                                       City of Seattle
                                                                      Seattle Fire Department (SFD)
                                                          Metropolitan Medical Strike Team (MMST)



v.           recommended cache inve ntory

             A. It is not the intent of the MMST to supplant existing on-scene units, but rather
                to support their efforts in terrorist incidents. However, to optimize MMST
                capabilities, a suggested list of the types of equipment that will be needed is
                provided below.

                    1.      PPE

                             Suits (levels A and B)

                             Breathing apparatus

                             Boots

                             Gloves

                             Helmets

                             Safety glasses/goggles

                             ‗‗GO‘‘ Kit (for each member)
                                Coveralls (with team insignia)
                                Personal mask
                                Personal antidote (Mark I NAAK autoinjectors, {4})
                                ‗‗GO‘‘ kit bag

                    2.      Detection and Monitoring Equipment

                             Papers
                                M8
                                M90
                                M256A-1




11/ 05/ 10                                                                                        8-4
                                                                          City of Seattle
                                                         Seattle Fire Department (SFD)
                                             Metropolitan Medical Strike Team (MMST)
                   Tubes
                      Draeger Kit

                   Point detectors
                      SAW minicad
                      Graize

                   Radiation Monitors
                      Ludlum 2241 beta/gamma meter
                      Thermoluminescent dosimeters (TLDs)
                      Self-reading dosimeters (SRDs)

             3.   Mass Decontamination Equipment

                   Showers
                      M-17 Lightweight Decon System (LDS)
                      RMC decon shelter
                      RMC decon shower
                      M-295 individual decon kits
                      Calcium Hypochlorite (HTH)
                      Overpack drums
                      Liquid hand pumps
                      Hoses, fittings, sprayers, and buckets for mixing decon
                       solution
                      Flags, cones, tape
                      Benches

             4.   Communications Equipment

                   Radios
                      Portables
                      Base station

                   Data Recorders

                   Telephones
                      Wired
                      Wireless
                      Satellite




11/ 05/ 10                                                                           8-5
                                                                             City of Seattle
                                                            Seattle Fire Department (SFD)
                                                Metropolitan Medical Strike Team (MMST)
             5.   Information Research

                   Laptop
                      High speed processor
                      Fax modem
                      CD ROM drive
                      Optical scanner capability
                      Software (EIS, CAMEO,               CABIN,       H/M      {CHRIS
                       Manuals}) and medical

                   Printer
                      Fax capable

                   Research books
                      MMST reading list

             6.   Command/Control and Transport

                   Portable shelter/tent

                   Portable generator

                   Storage/transport trailer

                   Personnel transport vehicle

                   Passport tags

                   Personnel command vests or functional identifier

                   Command post administrative supplies
                      Pencils, pens, and paper
                      Tables
                      Dry erase boards
                      Wireless phone(s)




11/ 05/ 10                                                                              8-6
                                                                                         City of Seattle
                                                                        Seattle Fire Department (SFD)
                                                            Metropolitan Medical Strike Team (MMST)
                           METROPOLITAN MEDICAL STRIKE TEAM

                                     COMMUNICATIONS GROUP


A communications team shall provide support to the Metropolitan Medical Strike Team
(MMST), beginning with preplanning and preparation, activation of the team upon
notification of a suspected event, ensuring reliable communications throughout an
incident, recording the event, and ending with the termination of the event.

Goal: The ability of all members of an emergency response team to communicate
reliably:

                Communications Dispatch Center to incident

                Incident to Communications Dispatch Center

                Internally at the incident

                Incident to supporting resource agencies

                  -   Receiving hospitals
                  -   U.S. Department of Health and Human Services
                  -   Military resources
                  -   Law enforcement agencies
                  -   Emergency Operations Center
                 -    Other


I.           COMMUNICATIONS REQUIREMENTS

     A. Preactivation

                      1.     Developing and updating resource lists as necessary and
                             distributing to appropriate agencies; ensuring that Memorandums
                             of Understanding (MOU) exist and are current between local
                             jurisdictions and local service providers. (For example, local
                             telephone companies agree to provide wireline service to incident
                             command post, and cellular/Personal Communication System
                             (PCS) vendors agree to provide portable communications sites.)

                      2.     Training and ensuring Public Safety Communications Dispatch
                             Centers have the ability to activate the MMST by using the
                             activation guidelines and resource materials relevant to nuclear,
                             biological, and chemical (NBC) events.



11/ 05/ 10                                                                                          9-1
                                                                                  City of Seattle
                                                                 Seattle Fire Department (SFD)
                                                     Metropolitan Medical Strike Team (MMST)
                  3.    Ensuring ongoing testing and maintenance of hardware assigned to
                        the MMST.


     B. Incident Support/Significant Event

             1.   Support of Command Post Activities

                  a.    Communications Dispatch Center

                               (1) Activation of MMST when an NBC incident has been
                                   identified by the Incident Commander (IC).


                  b.    On scene

                               (1) Establishing an on-site communications area for
                                   MMST activities in a location convenient to MMST
                                   command and in support of and coordinated with the
                                   Plans Section.

                                      On-site communications resource area for MMST
                                      On-site logging of activities

                               (2) Programming and distributing portable radios to all
                                   MMST personnel.

                               (3) Securing additional on-site communications abilities
                                   (hardwire telephones and portable cellular/PCS sites),
                                   directing their installation, and providing the hardware
                                   to utilize the expanded capability effectively.

                               (4) Acting as liaison between the MMST and controlling
                                   jurisdiction Communications Dispatch Center.

                               (5) Developing communications strategy allowing inter-
                                   operability of on-site agencies and providing support to
                                   ensure that programming can be completed and/or
                                   radios exchanged to maximize the teams‘
                                   effectiveness.

                  c.    Incident Termination

                               (1) Account for all MMST communications equipment;
                                   restore to ready state.


11/ 05/ 10                                                                                   9-2
                                                                                City of Seattle
                                                               Seattle Fire Department (SFD)
                                                   Metropolitan Medical Strike Team (MMST)
                            (2) Oversee the removal of on-site communications
                                installations.

                            (3) Forward all communications logs to Plans Section.


II. RESOURCES

     A. Hardware (See Appendix 1)

     B. Communications Frequencies/Channels

              Each MMST should equip to utilize the following dedicated
              frequencies/channels. In addition, an MMST communications section
              should assemble a working strategy to use local communications
              frequencies/channels to promote local communications with all involved
              jurisdictions and disciplines.

                          1.     Dedicated MMST frequencies/channels, (800
                     MHz encryption capable) per the Communications Plan.

              2.     Juris dictional communications frequencies/channels

              a.     Fire/Rescue
              b.     Emergency Medical Services (EMS)
              c.     Law Enforcement
              d.     Public Safety common frequencies/channels
              e.     Other Governmental frequencies/channels
                     (Public Works, Environmental Services, etc.)

              3.     Dedicated mutual aid frequencies/channels for surrounding
                     jurisdictional use

              a.     Fire mutual aid frequencies/channels
              b.     EMS mutual aid frequencies/channels
              c.     Law Enforcement mutual aid frequencies/channels
              d.     Other area-wide Public Safety frequencies/channels



              4.     Federal frequencies/channels

              a.     Federal agencies located within jurisdiction


              5.     Military frequencies/channels

11/ 05/ 10                                                                                 9-3
                                                                  City of Seattle
                                                 Seattle Fire Department (SFD)
                                     Metropolitan Medical Strike Team (MMST)


             a.   U.S. Army
             b.   U.S. Navy
             c.   U.S. Coast Guard
             d.   U.S. Air Force




11/ 05/ 10                                                                   9-4
                                                                                       City of Seattle
                                                                      Seattle Fire Department (SFD)
                                                          Metropolitan Medical Strike Team (MMST)
                                           APPENDIX 1

                    RECOMMENDED COMMUNICATIONS HARDWARE


The National Public Safety Planning Advisory Committee (NPSPAC) channels in the
800 MHz frequency/channel spectrum are recommended for MMST use because:

                 Five consecutive channels are available nationally so multiple responding
                  teams can use them regardless of incident location.

                 The spectrum represents current and future technology.

                 Radio systems operating in this spectrum can be purchased in digital format
                  for secure communications.

                 Most metropolitan public safety agencies are planning migration to 800 MHz
                  so a radio system of this design could be incorporated into an existing radio
                  system infrastructure.


I.           RADIOS

             A.      Base Station Radio

                        Full- featured 100-watt base station radio with ability to scan 10
                         channels and patch UHF/VHF/800 MHz. Also necessary are antennas,
                         associated cables, and headset.

             B.      Voice/Data Logger

                        Ability to record 40 channels including hardwire telephone service.
                         Format of logging media to be determined by each team.

             C.      Independent AC or DC Powe r Unit

                        Sufficient wattage and voltage to power base station,
                         amplifier/repeater, charger units, and associated communications
                         hardware.




11/ 05/ 10                                                                                        9-5
                                                                                       City of Seattle
                                                                      Seattle Fire Department (SFD)
                                                          Metropolitan Medical Strike Team (MMST)
             D.      Portable Amplifier/Repeater System

                        Handtruck mounted to provide an antenna and retransmit capability if
                         target hazards are present within a jurisdiction where communications
                         could be impaired (e.g., underground subway stations).

             E.      Portable Radio Multiple Battery Charge r Units

                        Sufficient chargers to provide one spare battery for each member of
                         the MMST.

             F.      Portable Radios

                        A minimum of sixty-two (62) radios assigned to members of the team
                         for use during activation. These radios should be digital, encryption
                         capable, and should be supplied to team members with spare battery
                         and individual charger. Input is necessary from HazMat teams for
                         recommendations of using external microphones in encapsulated suits.
                         Radios should be intrinsically safe and meet Military specifications for
                         weather and safe decontamination.

                        Laptop computer and software for programming portable radios on
                         site.

                        Portable radio programming hardware and cables for most commonly
                         used portable radios.


II.          TELEPHONES

                     A.    Stand-Alone Telephone           Distribution      System       with    12
                     Telephones (1A 2-key system)

                        Allows one trunkline to be dropped to command area by local
                         telephone company; then 12 prewired phones are available for
                         command use. Wireline telephones allow for secure conversations.
                         Schematic available.


III.         CELLULAR/PCS TELEPHONES

                 Six cellular/PCS telephones assigned to section leaders (necessary to
                  coordinate response of MMST and initial on-scene communications).
                 Fax machine (cellular/PCS transmission capable).



11/ 05/ 10                                                                                        9-6
                                                                                   City of Seattle
                                                                  Seattle Fire Department (SFD)
                                                      Metropolitan Medical Strike Team (MMST)


IV.          ALPHANUMERIC PAGERS

                Two-way preferred so alphanumeric responses can be sent and receiver can
                 provide a preprogrammed response back to the initiation center.

V.           PERSONAL PROTECTIVE EQUIPMENT

                Two communications personnel on site for team support will require
                 appropriate personal protective equipment (PPE) for the event as
                 recommended by MMST operational officers.




11/ 05/ 10                                                                                    9-7
                                                                                         City of Seattle
                                                                        Seattle Fire Department (SFD)
                                                            Metropolitan Medical Strike Team (MMST)

                       METROPOLITAN MEDICAL STRIKE TEAM (MMST)
                                     PHARMACEUTICAL S UPPORT


I.           INTRODUCTION

             This section identifies the pharmacological aspects of mitigating the
             consequences of the untoward release of chemical, biological, or radiological
             agents within the community. The plan will deal with the Metropolitan Medical
             Strike Team‘s (MMST‘s) role in providing pharmacological support to the first
             responder community, on-scene patient care, and support for hospitals providing
             primary care to the victims of these incidents.


II.          CHEMICAL AGENT INCIDENT

             A. For the purposes of this section, a Chemical Agent Incident will be defined as
                one involving the following chemicals:

                  1.    Non-persistent ne rve agents: tabun (GA), sarin (GB), soman (GD),
                        and GF.

                  2.    Persistent ne rve agent (VX).

                  3.    Blood agents: hydrogen cyanide (AC), cyanogen chloride (CK), and
                        arsine (SA).

                  4.    Blister agents: mustards (H, HD, HT, HN-1, HN-2, and HN-3);
                        arsenicals (L, HL, PD, ED, MD); and urticants (CX – phosgene
                        oxime).

             B. A chemical agent is defined as any chemical substance that, because of its
                physiological effects, is intended for use in military operations to kill,
                seriously injure, or incapacitate personnel. Chemical agents include all items
                in A. above, as well as choking agents (phosgene (CG) and diphosgene (DP)),
                tear agents, and vomiting agents.

             C.        First Responder Support/Protection

                  1.    The MMST will bring to the scene sufficient quantities of antidotes
                        to support the members of the MMST, emergency responders, and
                        support personnel.




11/ 05/ 10                                                                                      10-A-1
                                                                                       City of Seattle
                                                                      Seattle Fire Department (SFD)
                                                          Metropolitan Medical Strike Team (MMST)

                  2.    Each me mber of the MMST will be issued appropriate antidotes
                        against known chemical agents for self-administration in the event
                        of exposure.


             D.        On-Site Patient Care

              The MMST Pharmaceutical Cache will contain or have access to sufficient
              quantities of chemical agent antidote to handle an estimated 1,000 patients
              while in the incident site triage, treatment, and transport process.

                         Projected Numbe r of Patients Requiring Treatment in Field
                                         (Sorted by Triage Color)

                                  10 Black                           No Treatment
                                  100 Red                           3 Doses/ patient
                                300 Yellow                          2 Doses/patient
                                 600 Green                         +/- 1 Dose/patient


             E.        Hospital Support

              The MMST also will have access to a quickly deployable stockpile of
              appropriate antibiotics for the treatment of infected patients if the local health
              care facility cannot keep up with the demand for these antibiotics from their
              own sources.


III.         BIOLOGICAL AGENT INCIDENT

             A. For the purposes of this section, a Biological Agent Incident will be defined as
                the release of any etiological agent capable of causing mass casualties. These
                agents may include, but are not limited to, anthrax (bacillus anthracis);
                botulism (clostridium botulinum); SEB (staphylococcal enterotoxin B); and T-
                2 (trichothecene mycotoxin).


             B. First Responder Support/Protection

                  1.    Membe rs of the MMST should receive vaccinations against agents
                        (where vaccines exist) as recommended by the U.S. Public Health
                        Service, Centers for Disease Control and Prevention (CDC), and the
                        Medical Director.




11/ 05/ 10                                                                                    10-A-2
                                                                                                City of Seattle
                                                                               Seattle Fire Department (SFD)
                                                                   Metropolitan Medical Strike Team (MMST)

                  2.     Given the nature of the Biological Agent Incident, there is little
                         pharmaceutical protection available to the first responder, nor is
                         there any efficacy in widespread vaccination of the first responder
                         community against biological agents.


             C.        Concept of Operations

              Given the nature of biological agents and their inherent incubation period, it is
              highly likely that the release of an agent may not be known for days or even
              weeks. A specific incident site may not be able to be determined due to the
              dissemination of those persons infected at the time of release. The role of the
              MMST in these types of incidents may be to assist and support the Public
              Health efforts at identifying and tracking patients, disseminating information to
              care providers and the public, and assisting the law enforcement community in
              determining the site of release and in collecting evidence.

             D.        Hospital Support

              The MMST will be able to support local health care facilities with information
              regarding the toxins involved (once determined) and appropriate treatment
              protocols. The MMST also will have access to a quickly deployable stockpile
              of appropriate antibiotics for the treatment of infected patients if the local health
              care facility cannot keep up with the demand for these antibiotics from their
              own sources.


IV.          RADIOLOGICAL INCIDENT

             A. For the purposes of this section, a Radiological Incident will be defined as one
                where radioactive material is released, either by explosive or non-explosive
                means, with the intent to injure or kill personnel.

             B.        First Responder Support/Protection

                  Under development at the time of this publication.

             C.        On-Site Patient Care

      Unde r development at the time of this publication.


             D.        Hospital Support

              The MMST will be able to support local health care facilities with information
              regarding the radiological emergency (once determined) and appropriate
              treatment protocols. The MMST also will have access to a quickly deployable
              stockpile of appropriate medications for the treatment of affected patients if the

11/ 05/ 10                                                                                             10-A-3
                                                                                    City of Seattle
                                                                   Seattle Fire Department (SFD)
                                                       Metropolitan Medical Strike Team (MMST)

             local health care facility cannot keep up with the demand for these medications
             from their own sources.




11/ 05/ 10                                                                                 10-A-4
                                                                                            City of Seattle
                                                                           Seattle Fire Department (SFD)
                                                               Metropolitan Medical Strike Team (MMST)

                                              APPENDIX A

SUGGESTED PHARMACEUTICAL PRODUCT LIST



PROJECTION FOR PHARMACEUTICALS

PRODUCT                                                                      NUMB ER OF UNITS

                      D5W 125ml                                                        500
                 * Ciprofloxocin 500mg                                                 750
                 Albuterol MDI 6.8gm                                                   750
             Atropine/Tupan Auto Inject Kit                                           1500
                 Atropine Preloads 1mg                                                 150
                    Diazapam 10 mg                                                     750
               Methylprednisdone 125 mg                                                750
              Aminophyline 250mg preload                                               400
                 Cyanide Antidote Kit                                                  30
                   Potassium Iodide                                              5 bottles,
                                                                        (equivalent to 10,000 doses)




PROJECTIONS FOR EQUIPMENT TO SUPPORT PHARMACEUTICALS

                      PRODUCT                                                NUMB ER OF UNITS

             Container Boxes (Rubber Maid)                                              5
               Back Pack bags (Thomas)                                                 15

* - The quantity of Ciproflo xocin is limited. This amount is intended to treat team members and first
responders only.




11/ 05/ 10                                                                                           10-A-1
                                                                                       City of Seattle
                                                                      Seattle Fire Department (SFD)
                                                          Metropolitan Medical Strike Team (MMST)
                                            APPENDIX B

                             METROPOLITAN MEDICAL S TRIKE TEAM
                       PHARMACEUTICAL CACHE PROCUREMENT AND RES UPPLY



I.           PURPOSE

             To provide a standard operating procedure for obtaining the secondary
             pharmaceutical cache and replacing the expended or due-to-expire components of
             the primary cache.



II.          PROCESS FOR BUILDING UP THE PHARMACEUTICAL CACHE AND
             PROCURING A SECONDARY CACHE

             A.        The Task Force Leader, Logistics Section Chief, Medical Director and
                       Hospital Liaison must determine the need for procuring additional
                       pharmaceuticals beyond those already found in the primary
                       pharmaceutical cache.

             B.        If the need for a buildup of the pharmaceutical cache is determined, the
                       Task Force Leader or his/her designee will:

                  1.     Contact the IC and inform them of a need for pharmaceutical
                         replenishment. The IC will contact the Emergency Operations Center
                         for assistance.



III. PROCESS FOR EXCHANGING OR REPLACING PRIMARY CACHE
ITEMS

             A. A procedure will be established for the replacement or exchange of
                pharmaceutical items to ensure the readiness of the MMST.




11/ 05/ 10                                                                                               10-B-1
                                                                                       City of Seattle
                                                                      Seattle Fire Department (SFD)
                                                         Metropolitan Medical Strike Team (MMST))

                        METROPOLITAN MEDICAL STRIKE TEAM

                  RECOMMENDED MEDICAL SURVEILLANCE GUIDELINE


I.           PURPOSE

             A.     The purpose of the Medical Surveillance Protocol is to delineate the
                    medical surveillance guidelines to be followed by the Metropolitan
                    Medical Strike Team (MMST) before and after deployment.


II.          RESPONSIBILITY

             A.     The Safety Officer will coordinate the medical surveillance activities of all
                    team members.

             B.     The Team Medical Section Chief will be in charge of all pre/post- incident
                    medical surveillance activities.


III.         PRE-INCIDENT

             A.     All personnel will be required to complete the designated MMST health
                    forms on an annual basis.

             B.     The individual files of all team members will be computerized to assure
                    their immediate availability and completeness.

             C.     Team members must pass an annual physical examination given in
                    compliance with the Centers for Disease Control (CDC) and Public Health
                    Service (PHS) recommendations.

             D.     Team members will be required to maintain current immunizations
                    (including MMR, Polio, DPT).

             E.     Team members will be expected to maintain a state of physical fitness
                    appropriate to their respective height, weight, and age.

             F.     Task force member medical records will be maintained in a fashion that
                    assures their immediate accessibility, confidentiality, and completeness.

             G.     Team members will be given an annual review on Critical Incident Stress
                    (CIS) along with constructive ways to minimize its impact during and
                    after deployment.



11/ 05/ 10                                                                                       11-1
                                                                                      City of Seattle
                                                                     Seattle Fire Department (SFD)
                                                        Metropolitan Medical Strike Team (MMST))

             H.   Team members who incur an illness or injury that precludes them from
                  meeting their team obligations should notify the TFL immediately. Once
                  team members are returned to full duty, they should notify their TFL.


IV.          ON-SCENE

             A.   High-Risk Areas

                  Surveillance activities in high-risk areas will be as follows:

                  1.     Pre-entry medical monitoring

                         a.      Pre-entry medical monitoring will be conducted by
                         designated MMST members, under the direction of the Team
                         Medical Chief, prior to any team member dressing in personal
                         protective equipment (PPE).

                         b.     Intelligence information about the incident will be used to
                         determine whether immunizations need to be administered prior to
                         a team member entering into warm or hot zone activities.

                         c.     Team members may not be allowed to dress in PPE if they
                         have not met the exclusion criteria identified in Appendix C,
                         Pre/Post-Entry Monitoring Form.

                         d.      Prior to donning protective clothing, team members will be
                         expected to pre- hydrate themselves with 8 to 12 ounces of water or
                         exercise drink.

                         e.      Fellow team members will assist wherever possible in
                         donning PPE. Prior to entry into either warm or hot zone activities,
                         a fellow team member will conduct a suit check to assure proper fit
                         and function.

                         f.     Appropriate radiological exposure monitors will be issued
                         to each person wearing PPE if a radiological agent is suspected to
                         be involved.

                         g.     Medical information obtained during the pre-entry
                         monitoring will be recorded on the MMST Medical Surveillance
                         Form.




11/ 05/ 10                                                                                      11-2
                                                                            City of Seattle
                                                           Seattle Fire Department (SFD)
                                              Metropolitan Medical Strike Team (MMST))

             2.   During entry-observation

                  a.     Team members will be individually responsible for
                         conducting their operation in a safe manner.

                  b.      Team members will be responsible for constant
                  surveillance of each other when conducting their individual
                  responsibilities.

                  c.      Special attention should be paid to observing signs of suit
                  failure and medical or psychological emergencies involving team
                  members or other personnel working with members of the MMST.

                  d.      The time limitations for work activity in the hot and warm
                  zones will be established by the TFL or Section Officer and are to
                  be followed at all times.

             3.   Post-entry monitoring

                  a.      Upon completion of decontamination activities, each team
                  member will undergo a repeat medical examination and the results
                  will be recorded on the individual‘s MMST Medical Surveillance
                  Form.

                  b.      Appropriate radiological exposure monitors will be
                  recovered from each individual and will be read. The Team
                  Medical Section Chief will determine levels warranting further
                  evaluation.

                  c.     The post-entry examination will be followed by assignment
                  to the rehabilitation section where rest, rehydration, and caloric
                  intake will be undertaken

                  d.      Individuals who demonstrate any signs of illness or injury
                  will be managed in accordance with the appropriate medical
                  protocol and, where appropriate, transferred to a local medical
                  facility for further evaluation and treatment. If this occurs, the
                  TFL is to be notified immediately.

                  e.      Individuals showing abnormal vital signs and/or physical
                  complaints not felt to warrant transportation to the hospital will
                  continue to be monitored on-scene every 15 minutes. After one
                  hour, if the vital signs have not returned to normal, these
                  individuals are to be transported to the local medical facility for
                  further evaluation and treatment.


11/ 05/ 10                                                                            11-3
                                                                                     City of Seattle
                                                                    Seattle Fire Department (SFD)
                                                       Metropolitan Medical Strike Team (MMST))

                         f.      Team members are to be evaluated for abnormal reactions
                         for signs of CIS.

                         g.      Team members will be            given adequate time            for
                         rehabilitation prior to reassignment.


             B.   Low-Risk Areas

                  1.     The Team Medical Section Chief will determine the medical
                         monitoring of personnel working in low-risk areas after careful
                         evaluation of the situation and activities involved.

                  2.     All medical information obtained on individuals working in low-
                         risk areas will be recorded on their MMST Medical Surveillance
                         Forms.

                  3.     Steps will be taken to ensure that individuals will be periodically
                         reassigned to the Rehabilitation Section for rest, rehydration, and
                         caloric intake.

                  4.     All team members will be evaluated for signs of CIS.

                  5.     Team members who are determined to be ill or injured will be
                         transported to a medical facility for further evaluation and
                         treatment.


V.           POST-INCIDENT

             A.   Mandatory Defusing

                  1.     Following completion of the deployment, a mandatory defusing
                         will be held at a central, well-suited location determined by the
                         TFL.

                  2.     If possible, defusing will be conducted by MMST individuals who
                         are Critical Incident and Stress Debriefing (CISD) trained but were
                         not involved in the deployment. When these individuals are not
                         available, then available regional resources will be used.


             B.   Critical Incident Debriefing

                  1.     A critical incident debriefing will be held within 72 hours of the
                         incident.

11/ 05/ 10                                                                                     11-4
                                                                                   City of Seattle
                                                                  Seattle Fire Department (SFD)
                                                     Metropolitan Medical Strike Team (MMST))



                  2.    The incident debriefing will be conducted by qualified team
                        members and/or outside regional experts.

                  3.    All team members involved in the deployment will be strongly
                        encouraged to attend the activity. Participation in the discussion
                        will be left to the option of each participant.

                  4.    Individualized debriefings and other appropriate psychological
                        support will be provided by the team in conjunction with the
                        individual‘s employment jurisdiction.


             C.   Completion of Incident Health Forms

                  1.    Within 24 hours of the deployment ending, each team member will
                        complete the appropriate Incident Exposure Report Form (see
                        Appendix B) and submit it to the TFL.

                  2.    The MMST Medical Director will review completed forms.

                  3.    The evaluating physician will determine referrals for further
                        physical and/or psychological evaluation. Where necessary, the
                        individual will be sent to designated facilities to assist in further
                        evaluation.
                  4.    The results of the appropriate Incident Exposure Report Form will
                        be added to each individual‘s personal file.

                  5.    The final incident report written by the Plans Section Chief will
                        include a listing of the medical problems encountered by team
                        members and the follow-up action being taken.


             D.   Completion of a Health Survey

                  1.    Within 1 to 2 weeks after the deployment has ended, each team
                        member will be sent a health survey form to complete (Appendix
                        D). This form shall be returned to the address indicated on the
                        surveillance form.

                  2.    The MMST Program Management Team in a timely fashion will
                        tabulate the results of the survey. Individual and collective results
                        will be closely evaluated to determine whether any follow-up
                        education or further medical evaluation is warranted.



11/ 05/ 10                                                                                   11-5
                                                                                      City of Seattle
                                                                     Seattle Fire Department (SFD)
                                                        Metropolitan Medical Strike Team (MMST))

                  3.     The results of the survey will be shared in a timely manner with all
                         responders involved in the deployment.

                  4.     The results of the survey will also be added to each individual‘s
                         file and the composite data added to the deployment incident file.

                  5.     Where appropriate, team medical surveillance data will be shared
                         in a confidential manner with Federal or State officials.


             E.   Epidemiological Surveys

                  1.     Depending upon the nature of the incident, additional data forms
                         from Federal, State or Local agencies may need to be completed.
                         No team member will be expected to complete a survey/data form
                         unless the MMST Medical Director has preapproved its utilization.

                  2.     Individual research scientists may ask for team members to
                         participate in epidemiological studies associated with the
                         deployment. No team member is to complete the survey unless the
                         MMST Medical Director has preapproved it.


             F.   Family Support

                  1.     Depending upon the nature and circumstances surrounding a
                         deployment, MMST members not involved in the deployment may
                         be asked to provide support to family members whose loved ones
                         are participating in the deployment.        Sharing of accurate
                         information in an appropriate and timely fashion will be of utmost
                         importance.

                  2.     Some family members may be encountering emotional difficulties
                         associated with their loved one‘s deployment. This individual‘s
                         home jurisdiction services or community social services should be
                         utilized to provide family support per the local protocol.


VI.          APPENDICES

             A.   Metropolitan   Medical       Strike      Team        Physical       Examination
                  Components/History Form

             B.   Metropolitan Medical Strike Team Incident Exposure Report

             C.   Metropolitan Medical Strike Team Pre/Post-Entry Monitoring Form
11/ 05/ 10                                                                                      11-6
                                                                                City of Seattle
                                                               Seattle Fire Department (SFD)
                                                  Metropolitan Medical Strike Team (MMST))



             D.   Sample Post-Deployment Health Survey




11/ 05/ 10                                                                                11-7
                                                                                    City of Seattle
                                                                   Seattle Fire Department (SFD)
                                                      Metropolitan Medical Strike Team (MMST))
                                        APPENDIX A

                                         SAMPLE
                          METROPOLITAN MEDICAL S TRIKE TEAM
                          PHYS ICAL EXAMINATION COMPONENTS



I.           ADMINISTRATIVE

             A.   The Medical Director will be responsible for ensuring that team members
                  have successfully completed the required Metropolitan Medical Strike
                  Team (MMST) physical examination on an annual basis.

                  1.     Personnel having the examination completed through their
                         department/agency may meet the examination requirement, or the
                         Medical Director using outside resources will arrange a separate
                         examination.

             B.   Each MMST member‘s physical examination file will be kept intact from
                  year to year in the MMST Office.

             C.   Designated sections of each MMST member‘s file will be reproduced and
                  kept in a secure location in the medical cache to be used by emergency care
                  personnel in the event that a team member becomes ill or injured during a
                  deployment or training exercise.

             D.   All medical information on each MMST member will be kept confidential
                  and not released without the permission of the team member.

             E.   The MMST Medical Director will review annually the files of all team
                  members to determine their team eligibility for the following year. This
                  evaluation will be done upon receipt of the most recent annual physical
                  examination.

             F.   It will be the responsibility of all team members to ensure their latest
                  physical examination results are submitted to the MMST Office.

             G.   Team members not meeting Team physical fitness requirements (as
                  determined by the MMST Medical Director) will not be allowed to
                  participate in a deployment or training exercise until such time as they
                  meet the requirements.

             H.   All team members are expected to keep the following immunizations
                  current:

                  1.     Tetanus
                  2.     Diphtheria

11/ 05/ 10                                                                                 11-A-1
                                                                                    City of Seattle
                                                                   Seattle Fire Department (SFD)
                                                      Metropolitan Medical Strike Team (MMST))
                  3.     Hepatitis
                  4.     Measles, mumps, rubella (MMR)
                  5.     Polio

             I.   Verification of current immunizations must be submitted as part of each
                  annual physical examination report.


II.          SAMPLE EXAMINATION COMPONENTS: (UNDER DEVELOPMENT)

             A.   The annual physical examination components for all MMST members will
                  include the following

                  1.     Occupation-based history
                  2.     Complete physical examination including thorough assessment of:

                            Integument
                            Cardiovascular system
                            Respiratory system
                            Musculoskeletal system
                            Central nervous system
                            Psychological status

                  3.     Pulmonary function testing
                  4.     Electrocardiogram (ECG) stress test
                  5.     Resting ECG (for field record)
                  6.     CXR
                  7.     Body fat determination consistent with national standards for
                         height and weight
                  8.     Personal fitness via:

                            Timed 1.5- mile run appropriate for age
                            Weight lifting appropriate for weight and age
                            Flexibility appropriate for weight and age
                            Endurance appropriate for weight and age




11/ 05/ 10                                                                                 11-A-2
                                                                                     City of Seattle
                                                                    Seattle Fire Department (SFD)
                                                       Metropolitan Medical Strike Team (MMST))
                  9.     Blood assay that includes:

                          Complete blood count (CBC), CHEM 7, amylase, magnesium
                           (MG), phosphorous
                          Liver profile, (LD), aspartate aminotransferase (AST), alinine
                           aminotransferase (ALT), GGT, alkaline phosphatase, bilirubin
                           (total, conjugated), PT, PTT
                          Kidney function: UA, blood urea nitrogen (BUN), creatinine,
                           glucose
                          Triglycerides, total cholesterol, low-density lipoprotein (LDL),
                           high-density lipoprotein (HDL)
                          HIV
                          Tox Screen
                          Cholinesterase level

                  10.    Visual activity (i.e., color blindness evaluation)
                  11.    Stool, as appropriate


             B.   The examination results will be recorded by the examining physician on
                  the MMST physical examination record sheet and sent by the team
                  member to the Program Management Team Office as soon as possible.




11/ 05/ 10                                                                                  11-A-3
                                                                                       City of Seattle
                                                                      Seattle Fire Department (SFD)
                                                          Metropolitan Medical Strike Team (MMST)
                                                     APPENDIX B

                           METROPOLITAN MEDICAL STRIKE TEAM
                               INCIDENT EXPOSURE REPORT


DEMOGRAPHIC DATA

1) Last Name:                                                                               2) First Name:

3) Agency:                                     4) SSN:           -      -               5) Station:                         6)
Shift :

7) Incident Date:                              8) Incident No.:                                        9) Assignment:

SPECIFIC INCIDENT DATA

Incident Type (Circle one)
10) Poisonous Gas Release                             11) Et iologic Release                         12) Rad iation Incident

Level of Protection Worn (Circle one)
13) FF Ensemble            14) FF Ensemble/SCBA                      15) Splash Gear          16) Splash/SCBA            17)
Splash/APR
18) Encap. Suit            19) Other:

Activity Done (Circle one)
20) Entry-Recon        21) Entry -Rescue          22) Decon           23) Patient treat ment           24) Other:

Exposure Data (Check one)
25) Smo ke/FUM E/ Vapor Condition:                    __None                  __Light                         __Heavy
26) Type of Personal Exposure: __Inhaled __Ingested __Skin/Mucous Membrane Contact __Injection
__None
27) Exposure Risk:                      __ Direct Contact        __ Exposure        __ Near Exposure            __ None

Exposure Durat ion:       Place one of the fo llo wing exposure durations in the appropriate box in Table 1 for
                          each chemical or substance the Strike Team was exposed to.
                    A) <15 min.               B) 15-30 min.          C) 30-60 min.             D) 1-2 hr.           E) >2 hr.
Table 1.
                                                                     Light/
                                                 Vapor/              Heavy      Light       Solid/    Combustible                  Measured
 Write in the chemical or substance present       Gas     Dust        Mist      Mist       Powder       Product       Radiation    Quantity
28)
29)
30)
31)
32)




11/05/10                                                                                                                  11-B-1
                                                                                         City of Seattle
                                                                        Seattle Fire Department (SFD)
                                                            Metropolitan Medical Strike Team (MMST)
Scene Sy mptoms (Check Responses)

                                            At      After                                                            At      After
                                          Incident Incident                                                        Incident Incident

33)   Eye Irritation/Burning                __          __           39)       Headache                              __       __
34)   Coughing                              __          __           40)       Skin Irritation/Rash                  __       __
35)   Shortness of Breath                   __          __           41)       Throat Irritation                     __       __
36)   Respiratory Irritation                __          __           42)       C/P __                                __
37)   Abdominal Pain/Bleeding               __          __           43)       Other:
38)   Light-headedness/Dizziness            __          __           44)       Other:

Scene Medical Surveillance (Circle one)
                                                                                                                     Final Pre-entry
45) Pre -entry Assessment Done     __No       __ Yes            BP / P                R          T           EKG

                                                                                                                    Final Post-entry
                                                                BP / P                R         T            EKG

46) Decontamination Performed      __No       __ Yes
47) On-scene Treat ment            __No       __ Yes        __ Oral Flu ids                    __O2                __IV
                                                            __ Other:                                    ,
48) Transported to ED              __No       __ Yes        __ Hospital:

Post-Incident Analysis by Department Surveillance Officer

49) Date Form Reviewed:
50) M D Physical Exam Needed?                    __No        __ Yes, by Dr.
51) Lab Needed?       __No    __ Yes                                 Date:        /       /   Results:
                                                                     Date:        /       /   Results:
                                                                     Date:        /       /   Results:
                                                                     Date:        /       /   Results:

52) X-rays Needed?        __No     __ Yes                            Date:        /       /   Results:
                                                                     Date:        /       /   Results:
                                                                     Date:        /       /   Results:
                                                                     Date:        /       /   Results:
53) Date Results Discussed With Individual:             /        /         .
54) Final Disposition:    __ Full Duty       __ Light Duty           __ Injury Leave             __ Other:


Signature:                                                                         Date:




11/05/10                                                                                                           11-B-2
                                                                             City of Seattle
                                                            Seattle Fire Department (SFD)
                                                Metropolitan Medical Strike Team (MMST)
                                           APPENDIX C

                     METROPOLITAN MEDICAL STRIKE TEAM
                      PRE-/POST-ENTRY MONITORING FORM

  Name:                                 Date:              Incident #:               Assignment #:


  Exposure Ri sk:         (A) Direct Contact            (B) Exposure          (C) Indirect Exposure
  (D) None
  Work Activity:          (A) Hot Zone     (B) Decon       (C) Medical Care         (D) Other:

                                                      ENTRY #1           ENTRY #2            ENTRY #3
      EXAMINATION COMPONENTS/
         EXCLUSION CRITERI A                    Pre     Post      Pre      Post        Pre       Post
BP:      Systolic     100-150 mmHg
         Diastolic    < 90 mmHg
Pulse:                > 50'
                      < 110'
Respirations:         > 12'
                      < 20'
Temperature:          > 97
                      < 100
EKG Interpretation
Weight
Mental Status Examination Score
Skin Abnormalities (ra sh, wound)
              Yes ___         No ___
Lung Abnormalities (rales, wheezes)
            Yes ___          No ___
Abdomen Problems (pain, N/V,
diarrhea)
             Yes ___         No ___
Eye Abnormalities
              Yes ___          No ___
Musculoskeletal Abnormalities
              Yes ___       No ___
Medication Exclusion
              Yes ___          No ___
Examination Time
Final Status          1    2   3    4
Evaluator




  11/05/10                                                                                   11-C-1
                                                                                      City of Seattle
                                                                     Seattle Fire Department (SFD)
                                                         Metropolitan Medical Strike Team (MMST)
                                      METROPOLITAN MEDICAL STRIKE TEAM
                                      PRE-/POST-ENTRY MONITORING FORM


Prior to any physical functions of MMST members involved in entry evolutions or decontamination activities,
a pre-incident entry physical examination must be completed. Designated field operations personnel will
perform these examinations.

Due to the physical and mental demands of hazardous materials responses, it is imperative that the pre -
incident survey is completed quickly and effectively. The results of this survey will be used to determine the
suitability of team personnel to perform in personal protective clothing (PPE).

In order to adequately track each member's condition, each section of the examination has been developed
to place the hazardous materials responder into one of four possible categories as listed below:

Status 1 -      No condition exists that prevents the responder from performing any task on a hazardous
                material incident.

Status 2 -      A minor condition exists that will need to be re-evaluated in 15 to 20 minutes. During this time
                period, the responder will stay at rest and have no assignments placed on him/her. If after 15
                to 20 minutes this evaluation does not change or worsens, the responder will be placed into
                Status 3.

Status 3 -      A condition is present that will not allow a responder to wear PPE or perform any demanding
                or stressful work. This person will be re-evaluated in 15 to 20 minutes to be assured that the
                condition does not worsen. If after 15 to 20 minutes the condition does not change or
                worsens, the responder will be placed into Status 4.

Status 4 -      A serious condition exists that excludes the responder from any physical functions. The
                examining personnel should consider whether this person should be transported to the
                hospital. If questions exist, the Team Medical Section Chief should be consulted.

PHYSICAL SURVEY COMPONENTS/EXCLUSION CRITERIA

Blood Pressure: Systolic          100 - 150                                             Status 1
                                  < 100 (if not normal for the individual)              Status 2
                                  > 150                                                 Status 3

                    Diastolic     < 90                                       Status 1
                                  95 - 100                                              Status 2
                                  > 100                                                 Status 3

Pulse:              50 - 110                                                            Status 1
                    < 50 (if not normal for the individual)                             Status 2
                    >110                                                                Status 3

Respirations:       12 - 20                                                             Status 1
                    < 12                                                     Status 2
                    > 20                                                     Status 3

Temperature:        96 - 100                                                            Status 1
                    < 96                                                     Status 2
                    > 100                                                               Status 3

Weight:         To be recorded while responder is in shorts or coveralls. (Allow 2 pounds for coveralls.)




11/05/10                                                                                               11-C-2
                                                                                    City of Seattle
                                                                   Seattle Fire Department (SFD)
                                                       Metropolitan Medical Strike Team (MMST)
Skin:        Check appearance for any rashes or abnormalities. Document size and location of rashes. It
             will be at the discretion of the Team Medical Section Chief to determine when the rash,
             abnormality, etc., will allow the member to perform certain tasks. Personnel with open or
             weeping wounds should generally not be working in situations where skin absorption of a toxin
             is possible.

Eyes:        Check pupils for size and reactivity. Check eyes for appropriate movement. Comparisons
             should be made with the baseline examination to determine abnormalities. If gross differences
             exist, refer to physician. Status 4.

Lungs:       Listen for wheezes, rales, or bilateral equal sounds. If wheezes, rales, or unequal breathing
             sounds exist, the responder will be placed in Status 2 or Status 3, per the discretion of the
             Team Medical Section Chief.

Heart:       An y chest pain. Cardiac arrhythmia (with the exception of sinus arrhythmia). Status 3.

Abdomen:     An y abdominal pain/cramping                        Status 3
             Nausea or vomiting                                  Status 3
             Diarrhea                                            Status 3

Mental Status Examination (see attached worksheets):             Score 20 - 22                Status 1
                                                                 Score < 20                   Status 2

Musculoskeletal:           At the discretion of the Team Medical Section Chief, any recent or ongoing injury
                           may be placed into Status 2.

Recent Medical History:    If a member of the MMST has had a condition that required that person to be off
                           work within 48 hours of the response, a Status 2 is indicated.

Current Medications:       If a member is taking one of the following medications, that person will not be
                           allowed to wear Level A or B clothing:

                           -- Phenothiazines       -- Bronchodilator      -- Narcotics      -- Antihistamine
                           -- Decongestants        -- Antibiotics for respiratory, ear, or GI problems

Other:   If a member is under current treatment for middle ear, respiratory, genito -urinary, or gastrointestinal
         (GI) problems, that member should not be allowed access to SCBA or encapsulated clothing. Any
         other components or findings not listed above will be categorized at the discretion of the Team
         Medical Section Chief.

         If a member of the MMST has had a condition that prevented that member from working for 3 or
         more days within the past 7 days, that member shall not be put in a position that requires protective
         clothing.

         If a member of the MMST has a condition that requires wearing a cast, brace, etc., that team
         member shall not participate in a frontline position (hot or warm zone) unless cleared by a
         physician. Consideration should be given to that member’s working in a command function.




11/05/10                                                                                                 11-C-3
                                                                        City of Seattle
                                                       Seattle Fire Department (SFD)
                                           Metropolitan Medical Strike Team (MMST)
                       METROPOLITAN MEDICAL STRIKE TEAM
                        MENTAL STATUS EVALUATION FORM


 MAXIMUM           SCORE
   SCORE         PRE / POST

                                                                 ORIENTATION

       3               /      Oriented to person, place, and time?

                                                                REGISTRATION

       3               /      Name three objects:       One second to say each. Then ask the
                              Radio                       patient all three after you have said them.
                              Suit                          Give one point for each correct answer.
                              Truck                         Then repeat them until he/she learns all
                              three. Count trials and record number.

       5               /      Count serial 7s. One point for each correct answer. Stop after five
                              answers. Alternatively, spell ‘‘world’’ backwards.

                                                                    RECALL

       3               /      Ask for the three objects repeated above. Give one point for each
                              correct answer.

                                                                  LANGUAGE

       4               /      Name a pencil and watch. (2 points)
                              Repeat the following: ‘‘No ifs, ands, or buts.’’ (1 point)
                              Write your signature. (1 point)



Pre-signature:                                Post-signature:

ASSESSMENT OF LEVEL OF CONSCIOUS NESS THROUGH THIS MENTAL EXAMINATION
PROCESS

       4               /      Alert (1 point)
                       /      Drowsy (1 point)
                       /      Stupor (1 point)
                       /      Coma (1 point)

       22              /      TOTAL SCORE FOR THIS E XA MINA TION

Additional Comments:




11/05/10                                                                                   11-C-4
                                          City of Seattle
                         Seattle Fire Department (SFD)
             Metropolitan Medical Strike Team (MMST)
Appendix d




11/05/10                                          11-C-1
                                                                                       City of Seattle
                                                                      Seattle Fire Department (SFD)
                                                         Metropolitan Medical Strike Team (MMST)
  AAPCC        American Association of Poison Control Centers
  ABG          arterial blood gases
  AC           hydrogen cyanide
  AC           hydrocyanic acid
A CGIH         American Conference of Govern mental Industrial Hygienists
  AEA          Atomic Energy Act
  AG           Attorney General
AIHA           American Industrial Hygiene Association
  ALS          advanced life support
  ALT          alanine aminotransferase
  ANG          Army National Guard
  AO           Admin istrative Officer
AOEC           Association of Occupational and Environ mental Clinics
  ARDS         Adult Respiratory Distress Syndrome
  AS           arsine
  ASAP         as soon as possible
  ASH          Assistant Secretary for Health
  AST          aspartate aminotransferase
  ATP          adenosine triphosphate
ATSDR          Agency for To xic Substances and Disease Registry
  AV           atrioventricular

 BA L          British anti-Lewisite (dimercaprol)
 BOO           base of operations
 BLS           basic life support
 BP            blood pressure
 BTLS          Basic Trau ma Life Support
 BUN           blood urea nitrogen
BWAT           Biological Weapons Antiterrorism Act

 C             Celsius
 C/ B          chemical/bio logical
 CAS           Chemical Abstract Service
 CBC           complete b lood count
 CBDCOM        Chemical and Biological Defense Co mmand
 CBIRF         Chemical/ Bio logical Incident Response Force
 CCC           Casualty Collection Center
 CDC           Center(s) fo r Disease Control and Prevention
 CERCLA        Co mprehensive Environmental Response, Compensation, and Liability Act
 CG            Co mmand Group
 CGS           Co mmunicat ions Group Supervisor
 CIDC          Crisis Intelligence Dissemination Center
 CIS           Critical Incident Stress
 CISD         Crit ical Incident and Stress Management
 CK            cyanogen chloride
 CNS           central nervous system
 COG           Council of Govern ments
COPD           chronic obstructive pulmonary disease
 CPC           chemical p rotective clothing
 CPK           creatine phosphokinase
 CPR           cardiopulmonary resuscitation
 CS            Co mmunicat ions Specialist
 CX            phosgene oxime

 DC            direct current
 DDT           dichloro-diphenyl-trichloro-ethane



 11/ 05/ 10                                                                                       A-1
                                                                                           City of Seattle
                                                                          Seattle Fire Department (SFD)
                                                              Metropolitan Medical Strike Team (MMST)
DHHS              Depart ment of Health and Hu man Services
 dL               deciliter
 DMAT             Disaster Medical Assistance Team
 DMC              Disaster Management Co mmittee (Seattle)
 DNA              deoxyribonucleic acid
 DoD              Depart ment of Defense
 DOE              Depart ment of Energy
 DOT              Depart ment of Transportation
 DP               diphosgene

ECC               Emergency Co mmunicat ions Center (Arlington)
 ED               emergency department
 EKG              electrocardiogram
 EMS              Emergency Medical Services
EMSO              Emergency Medical Services
              Officer
 EMT              Emergency Medical Technician
EMT/P             Emergency Medical Technician
              /Paramed ic
 EOC              Emergency Operations Center
 EOD              Exp losive Ordnance Disposal
 EPA              Environmental Protection Agency
 ER               Emergency Roo m
ERDEC             Edgewood Research, Develop ment
                  and Engineering Center
 ERPG             Emergency Response Planning Guideline
 ESF              Emergency Support Function

 F                Fahrenheit
 FAC              Fire Alarm Center
 FBI              Federal Bureau of Investigation
 FBI HQ           FBI Headquarters
 FEMA             Federal Emergency Management Agency
 FM GS            Field-Medical Group Supervisor
 FOG              Field Operat ions Gu ide
 FRP              Federal Response Plan

 g                gram
G6PD              glucose-6-phosphate dehydrogenase
 GA               tabun
 GA O             General Accounting Office
 GB               sarin
 GD               soman
 GI               gastrointestinal

 HAZMAT           hazardous material
HAZWOPER          Hazardous Waste Operations and Emergency Response Regulation
 HCL              hydrochloric acid
 HDL              high-density lipoprotein
HHS               Depart ment of Health and Hu man Services
 HIS              HazMat Informat ion Specialist
 HIV              Hu man Immune Deficiency Virus
 HL               Hospital Liaison
 HMC              Harborview Medical Center
 HMO              Health Maintenance Office
 HMTA             Hazardous Materials Transportation Act



 11/ 05/ 10                                                                                           A-2
                                                                                         City of Seattle
                                                                        Seattle Fire Department (SFD)
                                                            Metropolitan Medical Strike Team (MMST)
 hr           hour
 HS           HazMat Specialist
 HTH          calciu m hypochlorite

  IARC        International Agency for Research on Cancer
  IC          Incident Co mmand
  IC          Incident Co mmander
  ICP         Incident Co mmand Post
  ICS         Incident Co mmand System
IDLH          immed iately dangerous to life and health
  IIS         Intelligence Informat ion Specialist
  IMS         Incident Management System
  IND         Improvised Nuclear Dev ice
  IV          intravenous

 JIC          Joint Informat ion Center
 JOC          Joint Operations Center

 kg           kilogram

 L            liter
LC50          lethal concentration (fatal to 50% of a test population)
 LD           lethal dose
LD50          lethal dose (fatal to 50% of a test population)
 LDH          lactate dehydrogenase
 LDL          low-density lipoprotein
 LDS          Lightweight Decon System
 LEL          Law Enforcement Liaison
 LFA          Lead Federal Agency
 LGS          Logistics Group Supervisor
 LP           Liver Profile
 LS           Logistics Specialist
 LSC          Logistics Section Ch ief

 m            meter
 MD           Medical Doctor
 MDI          methylene bisphengl isocyanete
 mEq          milliequivalent
 mg           milligram
 MG           magnesiu m
 MIC          methyl isocyanate
 MIS          Medical In formation Specialist
 mL           milliliter
 mm3          cubic millimeters
 mm Hg        millimeters of mercury
 MMR          measles, mu mps, rubella
 MMST         Metropolitan Medical St rike Team
 MOU          Memorandu m of Understanding
 MS           Medical Specialist (Firefighter Paramedic)
 MSDS         Material Safety Data Sheet
 MSHA         Mine Safety and Health Administration
 MTS          Medical Team Supervisor
 MW           mo lecular weight

 NA           not applicable



 11/ 05/ 10                                                                                         A-3
                                                                                       City of Seattle
                                                                      Seattle Fire Department (SFD)
                                                          Metropolitan Medical Strike Team (MMST)
 NAC          National Agency Check
 NBC          nuclear, bio logical, or chemical
 NDM S        National Disaster Medical System
 NEST         Nuclear Emergency Search Team
NFPA          National Fire Protection Asoc.
 NICP         Nuclear Incident Contingency Plan
 NIOSH        National Institute for Occupational Safety and Health
 NOA EL       no-observed-adverse-effect level
 NRC          Nuclear Regulatory Co mmission
 NTP          National To xico logy Program

 OSC          Operations Section Chief
 OSHA         Occupational Safety and Health Administration

 PAH          polyaromatic hydrocarbons
 PAM          pralido xime chloride
 PAPR         Powered Air Purifying Respirators
 PAS          Personnel Accountability System
 PBB          polybrominated biphenyls
 PCB          polychlorinated biphenyls
 PCC          Poison Control Center
 PCF          patient care forms
 PCP          pentachloro phenol
 Pco 2        partial p ressure of carbon dio xide
 PCS          Personal Co mmun ication System
 PD           Police Depart ment
 PEG          polythylene glycol
 Pel          permissible exposure limit
 PFT          pulmonary function test
 PGS          Plans Group Supervisor
 PHN          Public Health Nurse
 PHS          Public Health Service
 PIO          Public Informat ion Office(r)
 PMT          Program Management Team
 Po 2         partial p ressure of o xygen
 POC          point of contact
 PPE          personal protective equipment
 ppm          parts per million
 PPO          Preferred Provider Office
 PSC          Plans Section Ch ief
 PT           platinum
 PVP          polyvinyl pyrrolidone

RADS          reactive airways dysfunction syndrome
 RBC          red blood cell
 RDD          Radio logical Dispersal Device
REA C/TS      Radiat ion Emergency Assistance Center/Train ing Site

 SAIC         Special Agent in Charge
 SARA         Superfund Amend ments and Reauthorizat ion Act
 sc           subcutaneous
 SCBA         self-contained breathing apparatus
 SEB          staphylococcal enterotoxin B
 SFD          Seattle Fire Depart ment
 SIOC         Strategic Intelligence Operations Center
 SKCPH        Seattle King-County Public Health



 11/ 05/ 10                                                                                       A-4
                                                                                       City of Seattle
                                                                      Seattle Fire Department (SFD)
                                                          Metropolitan Medical Strike Team (MMST)
 SO           Safety Officer
 SOP          standard operating procedures
 SPD          Seattle Police Depart ment
 SRD          self-reading dosimeter
 SSN          Social Security Nu mber
 STEL         short-term exposure limit

 T-2          trichothecene mycotoxin
 TERIS        Teratogen Informat ion Serv ice
 TEU          Technical Escort Unit
 TF           Task Force
 TFL          Task Force Leader
 TMSC         Team-Medical Sect ion Chief
 TNT          trinitrotoluene
 TWA          time-weighted average

 UN           United Nat ions
USPHS/MMST    United States Public Health                       Serv ices Metropolitan Medical Strike
              Team
USPHS//OEP    U.S. Pub lic Health Serv ice/Office o f Emergency Preparedness
 US&R         Urban Search and Rescue
 USSS         U.S. Secret Service
 UV           ultraviolet

 VA           Veterans Admin istration
 VX           nerve agent persistent chemical




 11/ 05/ 10                                                                                         A-5
                                          City of Seattle
                         Seattle Fire Department (SFD)
             Metropolitan Medical Strike Team (MMST)




11/ 05/ 10                                           A-1

				
Lingjuan Ma Lingjuan Ma MS
About work for China Compulsory Certification. Some of the documents come from Internet, if you hold the copyright please contact me by huangcaijin@sohu.com