Nurseweek: Under Siege: Drill simulates bioterrorist attack’s effects on health care workers

Under siege
Drill simulates bioterrorist attack’s effects
on health care workers

By José Alaniz
July 10, 2000

Topoff 2000, part of a $3.5 million counterterrorism drill mandated by Congress, simulated a biological terrorist attack near Denver with chilling realism.

Photo: Corbis/
Pavel Zoudilov


	You've read the article. Now tell us what you think. Related Sites Topoff 2000 fact sheet Medical Center of Aurora Public Health Nursing Program, UNCCH CDC paper on bioterrorism as a public health threat

Karen Nerger, RN, died of pneumonic plague sometime after May 22 during a bioterrorist attack against the Denver metro area. The exhausted nurse had gone to help another patient on the floor of the Medical Center of Aurora’s ER wing. She neglected to don gloves or a gown.

The contaminated patient passed on the pneumonic plague’s Yersinia pestis bacterium to her and within 24 hours the first symptoms appeared: fever, headache and a cough with bloody, watery sputum. After 36 hours, the disease’s more severe effects manifested: chest pain, shortness of breath, nausea and septic shock as the plague bacillus ravaged Nerger’s lungs and immune system.

Several of her co-workers also contracted the plague and couldn’t help her; some had fled in terror. Inadequate supplies of antibiotics had already run out. Nerger – in her late 30s, married, mother of two – died.

By then, a desperate mob of 800 was storming the ER as mass panic swept Denver: 3,700 cases of pneumonic plague, with 950 deaths – and counting. The governor declared a state of emergency, several counties were quarantined, the army was on its way to quell disorder …

… In theory, that is.

Chilling realism
But Topoff 2000, part of a $3.5 million congressionally mandated counterterrorism drill held over 10 days in late May, certainly simulated a biological attack – and nurses’ experience in such a scenario – with chilling realism.

"It’s kind of scary, it really is," Nerger said. "We had never dealt with this serious a drill, with not having enough staff, enough ambulances, the families demanding to see their loved ones, staff members getting infected, the biological agent spreading so fast. But our staff worked well once we got all our ducks in a row."

Among other tasks, the ER staff at the Medical Center of Aurora had to quickly reorganize its operations to deal with the influx of 30 patients (played by quite vocal actors) and more than 800 "paper patients" during the simulation. Using the Med Teams system, the staff convened every 20 minutes to maintain a close line of communication as chaos threatened to overwhelm scarce resources.

"When everything gets crazy, you have to regroup," said Janet Shepard, MHA, RN, director of emergency services at the Medical Center of Aurora, who worked for almost a year with federal agencies to prepare the exercise. "You make more mistakes, duplicate work and lose efficiency when you don’t keep in touch with each other. This way, we meet for three to five minutes at regular intervals, make sure the equipment is working, divide the labor, get instructions from the team leader. Otherwise, you miss things."

Sobering simulation
The ER staff also went on a rotation of sleep six hours/work six hours, found creative alternatives to treatment with some over-the-counter drugs, worked closely with riot control officers, and pondered whether to quarantine demanding relatives of the fictional plague victims.

But, as Topoff 2000 demonstrated with sobering effectiveness, even the best system of care could collapse in a bioterrorist attack.

"It hit me when I saw that every bed was full, the hallways were full, we had no more resources and we had to tell the command center that we couldn’t take any more," Shepard said. "All our staff had been tapped out by the second day."

One other unusual danger arose: contracting and dying from plague.

"In a real bioterrorism situation, we would probably see more of the staff refusing to come in when we called them," Shepard said. "We found that some would rather stay home with their families than come in to help for $19 an hour and probably die of a horrible infection like the people they just saw on television."

Jana Williams, RN, trauma program director at the Medical Center of Aurora, worked as a controller during the exercise.

"We had staff on duty requesting to go home, because they were infected and wanted to die with their families. These are situations that a nurse’s training doesn’t usually address," Williams said.

"These individuals would meet with psych counselors and be given information about what they could expect in terms of the progress of the disease, and be given choices. It was really instructive, because most of them chose to stay in the end, but we did explore options for bringing their families closer to them," she said.

The government will release its Topoff 2000 report in the fall, but already most experts acknowledge the United States has woefully inadequate stockpiles of smallpox vaccine and antibiotics suitable to treat anthrax infection.

In addition, the communications infrastructure is unsuitable for dealing with a bioterrrorist attack. This makes the role of caregivers even more important in dealing with such a threat, especially in its early stages, said Rachel Stevens, Ed.D., RN, director of the Public Health Nursing Program at the University of North Carolina at Chapel Hill.

"There’s no question nurses will be in the front line of response," Stevens said. "What our training needs to accomplish is to have them recognize the signs and symptoms of a biological agent and report them to a clearinghouse. They need to identify and track the event, set up databases, follow standard epidemiological guidelines. People at every level need to be thinking.

"In some communities, a nurse may be the only one present to spot these signs; that’s why we all need to understand what we’re seeing."

The necessary training for a biohazard situation could take place over the Internet, through e-mail seminars or three-day workshops, Stevens said. But one way or another, only preparation will avert a disaster.

"Nursing could take a great step forward with training that emphasizes the psychological factor in emergency situations like this," Williams said. "The experts say it’s a matter not of if, but when something like this will happen.

"After this exercise, I operate under a different mentality. It struck me that this probably will happen in my lifetime – and not somewhere far away, but here. All we can do is train and train and train, and prepare our minds as well as our skills."

Or die trying.