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Hospital Emergency Response Training (HERT) for Mass Casualty Incidents (MCI) Train-the-Trainer Course Course Code: B461 HERT FOR MCI Hospital Emergency Response Training (HERT) for Mass Casualty Incidents (MCI) Train-the-Trainer, B461 Course Resident Offering at Noble Training Center, Anniston, Alabama 4.0 Days Special offerings for hospital emergency departments, administration, and staff personnel Prerequisites: IS-195, Basic ICS IS-346, An Orientation to Hazardous Materials for Medical Personnel DHS/NTC B461 Course 2 What HERT for MCI is Not? Not a HazMat Course. Need additional training under: OSHA’s Hazardous Waste Operations and Emergency Response, 29 CFR 1910.120, par (q), 1990 OSHA 3152 Hospital and Community Emergency Response – What You Need to Know, 1997 OSHA’s Best Practices for Hospital-Based First Receivers of Victims from Mass Casualty Incidents Involving Hazardous Substance Releases, 2004 Department of Health and Human Services, CDC Recommendations for Civilian Communities Near Chemical Weapons Depots: Guidelines for Medical Preparedness, 1995 USACHPPM, Technical Guide 275, PPE for Military MTF Personnel Handling Casualties from WMD and Terrorist Events, 2003 DHS/NTC B461 Course 3 What HERT for MCI is Not? (Cont’d) Not a Hospital Emergency Incident Command System (HEICS) Course: HERT stresses HEICS as a valuable tool for hospitals Recognizes all Hospital Incident Management Systems (HIMS) HERT emphasizes a hospital IMS during emergency response HERT integrates its HIMS into all aspects of the course DHS/NTC B461 Course 4 What HERT for MCI is Not? (Cont’d) Not a Weapons of Mass Destruction (WMD) Course: HERT emphasizes the handling of patients contaminated with CBRNE agents Recognizes attendee’s prior training and skills concerning these agents Attendees should receive additional training on WMD Events from ODP DHS/NTC B461 Course 5 What HERT for MCI is Not? (Cont’d) Not a National Incident Management System (NIMS) Course: HERT emphasizes the use of an incident management system to comply with the NIMS Recognizes attendee’s prior training in the NIMS Has incorporated NIMS where it applies throughout the course Participants wanting additional training should enroll in FEMA’s Online Courses in the NIMS: • IS 700 NIMS, An Introduction • IS 800 NRP, An Introduction DHS/NTC B461 Course 6 Unit One Course Introduction: Origin of the Incident Command System (ICS) Objectives Review ICS as an incident management tool List uses of ICS in emergency management Describe the history of ICS Discuss the evolution of HEICS Define basic HEICS structure Review ICS organizational chart DHS/NTC B461 Course 8 Objectives (cont'd) Develop an initial organizational structure List minimum staffing requirements Prepare an incident briefing Participate in a planning meeting Develop incident objectives and an Incident Action Plan (IAP) Identify appropriate uses of resources DHS/NTC B461 Course 9 What is ICS? The model incident management tool for: Command, control, and coordination of an emergency response Providing a means to coordinate efforts of individual agencies Allowing agencies to work toward a common goal for stabilizing an incident Ensuring the protection of life, property, and the environment DHS/NTC B461 Course 10 When is ICS Used? Hazardous materials incidents Response to natural disasters Fire and riot control Incidents involving multiple casualties: Weapons of Mass Destruction Mass Casualty Events Wide-area search and rescue missions DHS/NTC B461 Course 11 History of ICS Developed in the 1970s in response to major wild land fires in Southern California Allowed for collaboration to form the: Firefighting Resources of Southern California Organized for Potential Emergencies, or FIRESCOPE DHS/NTC B461 Course 12 History of ICS (cont'd) FIRESCOPE identified several recurring problems involving multi-agency responses, such as: Nonstandard terminology Lack of flexibility to expand or contract resources as required Nonstandard and nonintegrated communications Lack of consolidated action plans Lack of designated facilities DHS/NTC B461 Course 13 History of ICS (cont'd) Efforts to address these difficulties resulted in the development of an ICS model Success of ICS has resulted directly from applying: A command organizational structure Key standardized management principles DHS/NTC B461 Course 14 NIIMS versus NIMS NIIMS (existing): 1. Incident Command System (ICS) 2. Training 3. Qualifications & Certification 4. Publications Management 5. Supporting Technology DHS/NTC NIMS (new): 1. Command & Incident Management 2. Preparedness 3. Resource Management 4. Communications Information & Intelligence Management 5. Science & Technology Management B461 Course 15 Hospital Emergency Incident Command System (HEICS) Modeled after FIRESCOPE Early work by the Northern California Hospital Council California authorized a grant to Orange Country EMS for HEICS Project 91/92 Major rewrite of HEICS documents: Now provide the current HEICS Plan HEICS considered a model for hospital incident management system DHS/NTC B461 Course 16 HEICS Attributes HEICS attributes: Command, control, coordination, and intelligence Functional incident management system A dependable chain-of-command Improved communications through common language Flexibility in section (component) activation Prioritization of duties Adaptable to HazMat, WMD, and MCI DHS/NTC B461 Course 17 HEICS Attributes (cont'd) Organized documentation for improved financial recovery Facilitates effective mutual aid with: Other hospitals, and Agencies DHS/NTC B461 Course 18 Basic HEICS Structure Basic units of structure: Incident Commander Section Chiefs Directors Unit Leaders Officers DHS/NTC B461 Course 19 ICS Organizational Chart Represents lines of authority and communications Command element (IC and staff) Four functional sections: Planning Operations Logistics, and Finance/Administration DHS/NTC B461 Course 20 ICS Organization Incident Command Planning Section DHS/NTC Operations Section Logistics Section B461 Course Finance/ Administration Section 21 Incident Commander Incident Commander (IC): Defines the mission and ensures its completion Has overall control of incident or emergency response Can appoint a deputy commander DHS/NTC B461 Course 22 Command Staff Public Information Officer Incident Command Safety Officer Liaison Officer DHS/NTC B461 Course 23 Command Staff (cont'd) Command Staff is: Public Information Officer Liaison Officer Safety Officer Officers can also have Assistants DHS/NTC B461 Course 24 General Staff Incident Command Planning Section DHS/NTC Operations Section Logistics Section B461 Course Finance/ Administration Section 25 Planning Section Planning Section: Determines and provides for the continuance of each response objective Prompts and drives all Officers to develop: Short-range action planning Long-range action planning Responsible for preparing the IAP DHS/NTC B461 Course 26 Planning Section (cont'd) Planning Section Resource Unit DHS/NTC Situation Unit Documentation Unit B461 Course Demobilization Unit 27 Operations Section Operations Section: Carries out the objectives to the best of the staff’s ability Oversees and directs all response operations Determines needs and requests additional resources DHS/NTC B461 Course 28 Operations Section (cont'd) Operations Section Staging Area(s) Medical Branch DHS/NTC Rescue Branch Multi-Casualty Branch B461 Course HazMat Group 29 Logistics Section Logistics Section: Provides a hospitable environment and materials for the overall objectives Ensures service and support for responders DHS/NTC B461 Course 30 Logistics Section (cont'd) Logistics Section Service Branch Communications Unit Support Branch Supply Unit Food Unit Medical Unit DHS/NTC Ground Support Unit Facilities Unit B461 Course 31 Finance/Administration Section Finance/Administration Section: Provides funding for present objectives Stresses facility-wide documentation to maximize: Financial recovery, and Reduction of future liability DHS/NTC B461 Course 32 Finance/Administration Section (cont'd) Finance/Admin Section Time Unit DHS/NTC Procurement Unit Compensation /Claims Unit B461 Course Cost Unit 33 Future of the ICS Continues to expand throughout U.S.: Law enforcement Government agencies Hospitals and HCF Will be revisited to ensure: It remains relevant to response agencies, and Current with standardized ICS models Must be adaptable to include an ICS/UC structure for HMI, MCI, and WMD events Should incorporate NIMS as adopted on March 1, 2004 DHS/NTC B461 Course 34 Unit Two Hospital Incident Management System (HIMS) Objectives Describe Hospital Incident Management System for: Planned & unplanned events Mass casualty incidents HazMat incidents CBRNE events Describe transfer of command DHS/NTC B461 Course 36 HIMS – Operations Section Members HIMS Operations Section could consist of: Operations Section Chief Group/Division Supervisors • CBRNE or HazMat Group • SHED or Cafeteria Division, etc. Team Members Triage and Treatment Unit Leaders • Triage and Treatment Team Members Hospital Emergency Response Unit (HERU) • Team Members DHS/NTC B461 Course 37 HIMS – Operations Section Organization Operations Section SHED Division DHS/NTC Cafeteria Division B461 Course CBRNE Group 38 Medical Care Group/Division Members Medical Care Group/Division could consist of: Medical Group/Division Supervisor: • Triage Unit Leader Triage personnel • Treatment Unit Leader Treatment Dispatcher Manager Treatment Managers • Immediate, Delayed and Minor DHS/NTC Patient Transport Group Supervisor • Medical Communications Coordinator • Air/Ground Ambulance Coordinator B461 Course 39 Medical Care Group/Division Members (Cont’d) Command from the top down Staff from the bottom up: Start with Team or Unit when possible Staff up as span of control is exceeded Maintain unity of command Divisions are geographical: DHS/NTC North/South; East/West; 1st floor/2nd floor B461 Course 40 Medical Care Group/Division Members (Cont’d) Groups are functional: Security, medical care CBRNE or HazMat Groups can have Units: Triage Treatment Hospital Emergency Response Unit (HERU) Units may have Teams DHS/NTC Decontamination B461 Course 41 Medical Care Group/Division Organization Medical Care Group /Division Supervisor Medical Supply Coordinator Triage Unit Leader Treatment Unit Leader Triage Personnel Morgue Manager Treatment Dispatch Manager Immediate Treatment Manager Delayed Treatment Manager Minor Treatment Manager DHS/NTC B461 Course 42 HazMat/CBRNE Unit Members HazMat/CBRNE Unit Leader Entry Team Leader Hospital Site Access Control Leader Safe Refuge Area Manager Decontamination Team Leader Technical Specialist Assistant Hospital Safety Officer – HazMat DHS/NTC B461 Course 43 HazMat/CBRNE Unit Organization HazMat/CBRNE Unit Entry Hospital Access Control Safe Refuge Area Decontamination Technical Specialists DHS/NTC B461 Course 44 Hospital Emergency Response Unit* (HERU) HERU Leader Hospital Emergency Response Team (HERT) Leader Initial Assessment & Triage Immediate Treatment Delayed Treatment Minor Treatment *Unit can be replaced by a Team DHS/NTC B461 Course 45 HERU/HERT Organization HERU/HERT Leader Initial Assessment/ Triage DHS/NTC Immediate Treatment B461 Course Delayed Treatment Minor Treatment 46 Decon Team Members Decontamination Team Leader Initial Contact Decon Triage* Decon Site Access Control Decon Set-up and Support *Patient/victim is continually triaged DHS/NTC B461 Course 47 Decon Team Organization Decon Team Leader Initial Contact DHS/NTC Decon Triage Decon Site Decon Set Up/ Access Control Support B461 Course 48 Scenario Objectives Identify initial incident objectives Incident priorities Life Safety (staff and patients) Incident Stability Property preservation Activate ICS Fill positions as appropriate for the event Key points: DHS/NTC Span of control (3 – 7) Unity of command B461 Course 49 Scenario – Planned Event Menu: Noble Hospital is planning their annual fundraiser: Fried catfish, Cole Slaw, Beans, Hush Puppies, Cornbread Ice Cream Cones Beer Soda A two day Fish Fry Festival. Saturday and Sunday, Noon to 10 pm Entertainment: 8 bands, 2 magician shows Vendors: 20 Arts & Craft booths Children’s Play area DHS/NTC B461 Course 50 Section Considerations Initial Incident Objectives What are the main functions for: (Operations, Logistics, Planning and Finance/Admin)? Should the functions be divided? If so, how? DHS/NTC B461 Course 51 Scenario – Unplanned Event A complete, community-wide power outage has occurred approximately 20 minutes ago. United Electric Company has just informed you that there is a 50 mile blackout, cause is unknown. Outage expected to last 5-7 days. Emergency generators functioning with enough fuel for 1.5 days at current emergency load. Emergency equipment is working only. The following departments are not on emergency power: Business office Registration Infection Control Administration Physical Therapy All offices in hospital Pneumatic tube system DHS/NTC B461 Course 52 Scenario – Unplanned Event (Cont’d) Departments on emergency power for critical functions: Emergency Dept ICU/CCU Medical gases Lab XRay Nursery Surgery Recovery Nursing Units Pharmacy Switchboard Summer weather - 90°/58° Population 250,000 Two hospitals, multiple clinics in area Noble Hospital – 250 beds/85% full; total hospital staff 1800 DHS/NTC B461 Course 53 Section Considerations Initial Incident Objectives What are the main functions for: (Operations, Logistics, Planning and Finance/Admin)? Should the functions be divided? If so, how? DHS/NTC B461 Course 54 Scenario -- Mass Casualty Event There was a stadium collapse at the fairgrounds. Capacity of the stadium is 5000 people. Report from EMS indicate over 300 people injured with many fleeing the scene in private vehicles. The county Mass Casualty Plan has been activated. Summer weather - 90°/58° Population 250,000 Two hospitals, multiple clinics in area Noble Hospital – 250 beds/85% full; total hospital staff 1800 ED has 20 beds – currently has 16 patients DHS/NTC B461 Course 55 Section Considerations Initial Incident Objectives What are the main functions for: (Operations, Logistics, Planning and Finance/Admin)? Should the functions be divided? If so, how? DHS/NTC B461 Course 56 Scenario – Haz Mat Incident Continuation of stadium collapse There were 20 people that were contaminated With Organophosphate when the holding tank was punctured from a piece of the stadium Some have left the scene en-route to the hospital. EMS will be transporting 6 after gross decontamination (clothing removed and field shower) DHS/NTC B461 Course 57 Section Considerations Initial Incident Objectives What are the main functions for: (Operations, Logistics, Planning and Finance/Admin)? Should the functions be divided? If so, how? DHS/NTC B461 Course 58 Transfer of Command Transfer command to an equal or more qualified person Transfer of command requires: Briefing of incident face to face Notification of staff that transfer has occurred AND the name of the new person DHS/NTC B461 Course 59 Transfer of Command (Cont’d) Command transfers to a more qualified IC when necessary The new IC will always receive a transfer-ofcommand briefing Hospitals and healthcare facilities must identify and train deputy ICs DHS/NTC B461 Course 60 Summary ICS can be used for planned AND unplanned events involving the hospital Make the response fit the event – only fill the positions that are needed Maintain span of control (3 – 7 people) Use branches and divisions as needed Expand and contract assignments as needed Transfer of Command must be done consistently and completely DHS/NTC B461 Course 61 Summary (Cont’d) Incident priorities: Life safety of care providers Patient stability and treatment Property conservation Protect the environment DHS/NTC B461 Course 62 Unit Three Topic 3-1: Chemical and Biological Agents in Terrorism Objectives Overview of potential biological agents used in terrorism Overview of potential chemical agents used in terrorism Overview of common syndromes Define clinical management procedures for chemical/biological agents Define guidelines for response plans DHS/NTC B461 Course 64 Routes of Exposure for Chemical and Biological Agents Inhalation Inhalation of droplets, aerosols or vapors Absorption Intact skin, cuts or abrasions Mucous membranes Injection Intentional or unintentional Ingestion Specific agent ingestion Contaminated food or water DHS/NTC B461 Course 65 Bioterrorism (CDC Definition) “Bioterrorism is the intentional or threatened use of viruses, bacteria, fungi, toxins from living organisms or other chemicals to produce death or disease in humans, animals or plants.” DHS/NTC B461 Course 66 Potential Bioterrorism Agents Bacterial Agents DHS/NTC Anthrax Brucellosis Cholera Pneumonic plague Tularemia Q Fever Viruses Smallpox Venezuelan Equine Encephalitis Viral Hemorrhagic Fever Biological Toxins Botulinum Staph Entero-B Ricin T-2 Mycotoxins B461 Course 67 Mandatory Reporting Guidelines > Know your state and local guidelines > Include them in your plans AND > Train your staff DHS/NTC B461 Course 68 CDC Category Definitions of Diseases/Agents Category A - Highest priority Can be easily disseminated or transmitted from person to person Results in high mortality rates and have the potential for major public health impact Might cause public panic and social disruption Require special action for public health preparedness Category A – Agents DHS/NTC Anthrax (Bacillus anthracis); Botulism (Clostridium botulinum toxin); Plague (Yersinia pestis); Smallpox (variola major); Tularemia (Francisella tularensis); and Viral hemorrhagic fevers (filoviruses [e.g., Ebola, Marburg] and arenaviruses [e.g., Lassa, Machupo]) B461 Course 69 CDC Category Definitions of Diseases/Agents (cont) Category B – Second highest priority Moderately easy to disseminate Result in moderate morbidity rates and low mortality rates Require special enhancements of CDC’s diagnostic capacity and enhanced disease surveillance Category B – Agents DHS/NTC Brucellosis (Brucella species); Epsilon toxin of Clostridium perfringens; Food safety threats (e.g., Salmonella species, Escherichia coli O157:H7, Shigella); Glanders (Burkholderia mallei); Melioidosis (Burkholderia pseudomallei); Psittacosis (Chlamydia psittaci); Q fever (Coxiella burnetii) B461 Course 70 CDC Category Definitions of Diseases/Agents (cont) Category B – Agents (Cont) DHS/NTC Ricin toxin from Ricinus communis (castor beans); Staphylococcal enterotoxin B»Typhus fever (Rickettsia prowazekii); Viral encephalitis (alphaviruses [e.g., Venezuelan equine encephalitis, eastern equine encephalitis, western equine encephalitis]); and Water safety threats (e.g., Vibrio cholerae, Cryptosporidium parvum) B461 Course 71 CDC Category Definitions of Diseases/Agents (cont) Category C – Third highest priority Includes emerging pathogens that could be engineered for mass dissemination in the future because of > availability > ease of production and dissemination > potential for high morbidity/mortality rates and major health impact Category C – Agents DHS/NTC Nipah virus and hantavirus B461 Course 72 Most Common Syndromes in Biological Events Flu-like illnesses Acute respiratory symptoms with fever Gastrointestinal symptoms/syndromes Skin lesions (small pox) Acute neuromuscular syndromes Compliments of CDC/NIP/Barbara Rice DHS/NTC B461 Course 73 Clues to Biological Potential Events Increase in the number of patients with similar symptoms Large number of deaths Cluster of an illness from single area Infection that is not endemic to area Common infections in unusual seasons Increase/large number of sick/dead animals Intelligence from law enforcement Stated threat DHS/NTC B461 Course 74 Priorities for Response (All Hazards) Life safety Staff Victims Incident stability Property preservation Protection of the environment DHS/NTC B461 Course 75 Response Considerations for Biological Event Planning: Develop policies and procedures for: • recognition • notification • isolation/quarantine Pre-exposure: DHS/NTC Active immunization Prophylaxis Intelligence information B461 Course 76 Response Considerations for Biological Event (Cont’d) Incubation Period: Diagnosis Active/passive immunization Antimicrobial treatment Public Health needs (isolation/quarantine) Active Disease Period: Diagnosis Treatment (guided by diagnosis & symptoms) Public Health needs (isolation/quarantine) DHS/NTC B461 Course 77 Clinical Consideration for Biological Event Basic supplies/address surge capacity: Beds/linens Waste management Lab supplies Medical supplies: • IV solutions and supplies • Antibiotics (if needed) • Other medications DHS/NTC B461 Course 78 Clinical Consideration for Biological Event (Cont’d) Additional needs: Extended staffing plan (clinical/non-clinical) Medical staffing plan Mass casualty plan Mass fatality plan Media management plan (Joint Information Center) • Mechanism to provide updates/info to staff DHS/NTC B461 Course 79 Clinical Consideration for Biological Event (Cont’d) Additional needs: DHS/NTC Infection Control Practitioner (from hospital) Public Health representative Considering activating the hospital ICS/UCS Family support area Pharmaceutical stockpiles B461 Course 80 Key Points Some exposures may require decontamination but most do not Large events may overwhelm your system Assure that the right people are notified and included in the response Implement Incident Command System DHS/NTC B461 Course 81 Reminders Determine alternate care sites in the Planning Phase Work with community partners in the Planning Phase DHS/NTC B461 Course 82 Potential Chemical Agents Nerve Agents Blister Agents (vesicants) Pulmonary Agents Blood Agents (cyanides) Toxic Industrial Chemicals Riot Control Agents View from World Trade Center. Compliment of CDC. DHS/NTC B461 Course 83 Comparative Toxicity of Agents 6000 5000 4000 Ct50 (mg-min/m3) 3000 2000 1000 0 AGENT DHS/NTC CL CG AC (L) (L) (L) H GB VX (L) (L) (L) B461 Course 84 Nerve Agents Actions: Interferes with the action of the nervous system Similar to organophosphates Types: Sarin (GB) Tabun (GA) Soman (GD) GF VX Tokyo, Japan Response to Sarin Attack. DHS/NTC B461 Course 85 Blister Agents Actions: Cause cellular damage leading to cellular death (skin, mucous membranes, eyes, systemic effects) Effects begin immediately, but blisters may be delayed (mustard) Types: Mustard aka “mustard gas” (H) Sulfur mustard (HD) Lewisite (L) Mustard and Lewisite (HL) Phosgene Oxime (CX): • Pulmonary agent with vesicant effects Iran Victim of Mustard Agent Attack, CDC DHS/NTC B461 Course 86 Pulmonary Agents Actions: Damages the lining in the lung and cause fluid leakage Delayed pulmonary edema Types: Phosgene (CG) Chlorine (CL) Ricin Pulmonary edema. Compliments of CDC. DHS/NTC B461 Course 87 Blood Agents: Cyanides Actions: Blocks the use of oxygen in the cells of the body • Causing asphyxiation in each cell Least toxic of the “lethal” chemical agents Types: AC and CK Toxic industrial chemicals (TIC): Chlorine, ammonia, arsenic Hydrocarbon (benzene) Highly toxic, corrosive and irritating chemicals Likely terrorist’s targets of opportunity DHS/NTC B461 Course 88 Riot Agents Actions: Causes irritation to eyes, mouth, throat, lungs and skin Immediate symptoms are intense and cause people to try and stop the effects Types: Mace Pepper Spray DHS/NTC B461 Course 89 Clues To Potential Chemical Exposure Shortness of breath/respiratory difficulty Itchy/burning/watery eyes Runny nose Skin irritation SLUDGE Patients reporting odor just prior to symptoms DHS/NTC B461 Course 90 Clues To Potential Chemical Exposure (Cont) Increase number of patients with same symptoms Sick/dead animals and birds Sick/affected first responders Intelligence from law enforcement Stated threat DHS/NTC B461 Course 91 Planning Considerations for Chemical Agents Planning Phase Hazard assessment Designate Triage and Decon areas Develop Respiratory Protection Program Develop Decontamination Program Implement Incident Command System Purchase equipment Develop policies and procedures Train staff Practice and exercise DHS/NTC B461 Course 92 Response Plan Considerations for Chemical Agents Recognition Prevent secondary contamination Escort patient immediately outside/to decon area Initiate hospital HazMat response: Notify appropriate staff Don appropriate CPC&E DHS/NTC B461 Course 93 Response Plan Considerations for Chemical Agents (Cont) Determine need for decontamination Decontaminate patients Provide appropriate medical care Decontaminate staff Secure area Decontaminate equipment, as appropriate DHS/NTC B461 Course 94 Antidotes Are Available for Some Chemical Agents Nerve agents/organophosphates Atropine – blocks the effects of the chemical that causes over stimulation 2PAMCl – neutralizes the nerve agent actions CANA – Convulsive Antidote, Nerve Agent • Diazepam, when required Cyanide Cyanide Kit contains • Amyl nitrate (inhalant) • Sodium nitrite (injectable) • Sodium thiosulfate (injectable) DHS/NTC B461 Course 95 Hospital Partners for Biological & Chemical Response Plans PIO ED Staff Legal Risk & Materials Management Housekeeping HazMat Team Patient Laboratory Clinical Services Infection Control Plant Operations Hospital Emergency Management Administration DHS/NTC B461 Course 96 Community Partners for Biological & Chemical Response Plans EMS CDC Local Health Dept LEPC Local Haz Mat Team Hospital County Emergency Management State Lab Law Enforcement Elected Officials Media State Health Dept FBI DHS/NTC Coroner B461 Course 97 Key Points Some exposures may require decontamination but you must determine if patient was actually contaminated Large events may overwhelm your system quickly and without notice Notified and included the right people in the response DHS/NTC B461 Course 98 Summary Routes of exposure for chemical and biological agents Overview of some potential biological and chemical agents used in terrorism Overview of common syndromes Guidelines for response plans DHS/NTC B461 Course 99