The Psychological Dimension Of Chemical, Biological, Radiological And Nuclear (CBRN) Terrorism

Assessment of the effectiveness of a course in major chemical incidents for front line health care providers: a pilot study from Saudi Arabia

BACKGROUND

Mass chemical exposure emergencies are infrequent but can cause injury, illness, or loss of life for large numbers of victims. These emergencies can stretch and challenge the available resources of healthcare systems within the community. Political unrest in the Middle East, including chemical terrorist attacks against civilians in Syria and increasing chemical industry accidents, have highlighted the lack of hospital preparedness for chemical incidents in the region. This study aimed to evaluate the effectiveness of a course designed to empower frontline healthcare providers involved in mass casualty incidents with the basic knowledge and essential operational skills for mass chemical exposure incidents in Saudi Arabia.

METHODS

A mixed-methods approach was used to develop a blended learning, simulation enhanced, competency-based course for major chemical incidents for front line healthcare providers. The course was designed by experts from different disciplines (disaster medicine, poisoning / toxicology, and Hazard Material Threat - HAZMAT team) in four stages. The course was piloted over five days at the Officers Club of the Ministry of Interior (Riyadh, Saudi Arabia). The 41 participants were from different government health discipline sectors in the country. Pre- and post-tests were used to assess learner knowledge while debriefing sessions after the decontamination triage session and simulation-enhanced exercises were used for team performance assessment.

RESULTS

The overall knowledge scores were significantly higher in the post-test (69.47%) than the pre-test (46.3%). All four knowledge domains also had significant differences between pre- and post-test results. There were no differences in the pre and post-test scores for healthcare providers from the different health disciplines. A one-year post-event survey demonstrated that participants were satisfied with their knowledge retention. Interestingly, 38.3% had the opportunity to put this knowledge into practice in relation to mass chemical exposure incidents.

CONCLUSION

Delivering a foundation level competency-based blended learning course with enhanced simulation training in major chemical incidents for front line healthcare providers may improve their knowledge and skills in response to such incidents. This in turn can improve the level of national preparedness and staff availability and make a crucial difference in reducing the health impacts among victims.

Psychological effects of chemical weapons: a follow-up study of First World War veterans

BACKGROUND

Chemical weapons exercise an enduring and often powerful psychological effect. This had been recognized during the First World War when it was shown that the symptoms of stress mimicked those of mild exposure to gas. Debate about long-term effects followed the suggestion that gassing triggered latent tuberculosis.

METHOD

A random sample of 103 First World War servicemen awarded a war pension for the effects of gas, but without evidence of chronic respiratory pathology, were subjected to cluster analysis using 25 common symptoms. The consistency of symptom reporting was also investigated across repeated follow-ups.

RESULTS

Cluster analysis identified four groups: one (n=56) with a range of somatic symptoms, a second (n=30) with a focus on the respiratory system, a third (n=12) with a predominance of neuropsychiatric symptoms, and a fourth (n=5) with a narrow band of symptoms related to the throat and breathing difficulties. Veterans from the neuropsychiatric cluster had multiple diagnoses including neurasthenia and disordered action of the heart, and reported many more symptoms than those in the three somatic clusters.

CONCLUSIONS

Mild or intermittent respiratory disorders in the post-war period supported beliefs about the damaging effects of gas in the three somatic clusters. By contrast, the neuropsychiatric group did not report new respiratory illnesses. For this cluster, the experience of gassing in a context of extreme danger may have been responsible for the intensity of their symptoms, which showed no sign of diminution over the 12-year follow-up.

Terrorism, suicide bombing, fear and mental health

This paper is based on the Bruce Burns Memorial Trust Lecture, Terrorism and Mental Health, presented in October 2005, in Birmingham. In addition to written sources, it is informed by the author's experience and contact with military and police experts in this arena over 28 years as a member of the British Army. The diagnosis and treatment of post traumatic mental disorders are not addressed in this paper. The author explores the general phenomenon of terrorism, in an endeavour to inform understanding of terrorist acts. He stresses the need for contextualisation of acts of terror, their perpetrators, their effects on populations and individuals, and attention to the psychology of groups. The author aims to invite and inform further thought and debate on the subject by raising a wide range of issues which do not sit comfortably within a strict psychiatric, research-based paradigm. The author covers a brief history of terrorism; organisational requirements of terror groups and the process of recruiting personnel to them; the means, motives and opportunities terrorists exploit in their work; the need for communication with terror groups; sacrificial death; governmental responses to terrorist acts and fear and mental health. The author proposes that terrorist organisations perform some of the functions of a family; that acts of terror are 'propaganda by deed'; that terrorism, or more precisely the media's treatment of it, breeds 'formless fears' which may directly lead to the development of fear-based symptoms and illness within societies. He notes that terrorism is an enterprise from which many players ('experts', media, politicians, etc.) benefit; that terrorism has its shadow in counter-terrorism, which may range from benign to malignant and that psychiatry could, in this context, acknowledge its bias towards individual psychologies and rectify its lack of understanding of groups and the behaviours of individuals within them.

Assessing airway patency and breathing in NBC category 4R--the RG method

INTRODUCTION

Confirming airway patency and the presence of breathing has significant limitations when both the casualty and medical personnel are in NBC category 4R. In casualties with limited signs of breathing, IPE may adversely affect the efficiency of clinical assessment, and when the triage sieve is used this could result in the misdiagnosis of death. This manuscript describes and evaluates the Respirator-Glove (RG) method, of assessing airway patency and breathing in NBC category 4R.

METHODS

A medical examination glove was fitted over the primary speech module of the S10 NBC respirator of a volunteer casualty dressed in 4R. Two groups were studied; the first used an intact glove the second used a glove minus one finger. Breathing patterns A, B and C, representing normal breathing, hypoventilation and apnoea respectively, were randomly performed by the casualty for 15 seconds. A blinded observer recorded the glove inflation and movement and using these signs determined if breathing was present.

RESULTS

All of the randomly performed breathing pattern simulations were correctly identified in both groups, with glove inflation only occurring during exhalation. In the perforated glove group, the large expiratory air leak through the hole limited the development of continuous positive airway pressure and the respirator seal was maintained. In the non-perforated glove group the respirator seal was compromised. No difficulty was encountered attaching the gloves to the respirator speech module.

DISCUSSION

As an aid to clinical examination, the Respirator-Glove (RG) method provides a reproducible visual assessment of airway patency and spontaneous ventilation in unconscious 4R casualties. It can be utilised at any point in the evacuation chain, may improve the identification of T1 casualties and could reduce the risk of death being misdiagnosed. The efficiency of clinical assessment in 4R will improve by introducing the RG method into CBRN medical training programmes.

A psychosocial risk assessment and management framework to enhance response to CBRN terrorism threats and attacks

Evidence in the disaster mental health literature indicates that psychosocial consequences of terrorism are a critical component of chemical, biological, radiological, and nuclear (CBRN) events, both at the clinical level and the normal behavioral and emotional levels. Planning for such psychosocial aspects should be an integral part of emergency preparedness. As Canada and other countries build the capacity to prevent, mitigate, and manage CBRN threats and events, it is important to recognize the range of social, psychological, emotional, spiritual, behavioral, and cognitive factors that may affect victims and their families, communities, children, the elderly, responders, decision makers, and others at all phases of terrorism, from threat to post-impact recovery. A structured process to assist CBRN emergency planners, decision makers, and responders in identifying psychosocial risks, vulnerable populations, resources, and interventions at various phases of a CBRN event to limit negative psychosocial impacts and promote resilience and adaptive responses is the essence of our psychosocial risk assessment and management (P-RAM) framework. This article presents the evidence base and conceptual underpinnings of the framework, the principles underlying its design, its key elements, and its use in the development of decision tools for responders, planners, decision makers, and the general public to better assess and manage psychosocial aspects of CBRN threats or attacks.