Agent Release: At the site of a large-scale chemical agent release, there will likely be: large numbers of victims suffering symptoms with varying degrees of severity civilians panicking Victims could be experiencing difficulty breathing, disorientation, nausea, and convulsions.

	911 Response: The 911 operator will be the first non-civilian outside the affected area to receive notice of the attack. He or she may receive reports of mass casualties, dead animals, or unusual odors. The 911 operator will dispatch fire, police, emergency medical services, and hazardous materials (HAZMAT) personnel to the scene of the release. These agencies will be immediately responsible for responding to a chemical attack, and are thus referred to as "first responders." page 1 of 2

	911 Response: On arrival, the first responders will evaluate the situation. Indicators of a possible chemical attack include an explosion that caused little or no damage to structures; eyewitness reports of a device that dispersed a mist of vapor; numerous victims displaying similar symptoms with no visible signs of trauma; unusual odors, evidence of unusual liquids, dead animals, or discarded spray devices, cylinders, or personal protective equipment. First responders will alert hospitals to expect mass casualties. page 2 of 2

	Self-Evacuation: Some victims who are able to go by themselves will leave to seek treatment at area hospitals and other medical facilities. They may travel by car, bus, taxi, or even on foot.

	Rescue Begins: When dealing with any chemical terrorist attack, the first tasks of first responders are to learn more about the nature and severity of the threat and to secure the area. · Determining the nature and severity of the threat involves identifying the type of agent (see below), assessing the risks to responders as well as to the community, identifying if there are still live casualties in the area of the attack. · Securing the area can involve looking for other devices and establishing a perimeter away from the affected area in order to protect responders and the public (this "safe area" is usually upwind from the release site). At this stage, rescue workers will use HAZMAT response protocols, including putting on protective clothing and breathing equipment.

	Additional Units Called: After first responders identify the incident as a chemical attack, they will summon additional units as needed. These can include additional police, fire, and EMS units; other HAZMAT teams; the bomb squad; EMS/Fire task forces, or a command bus; DMAT (Disaster Medical Assistance Team) or units of the MMRS (Metropolitan Medical Response System); an FBI Evidence Collection Team; or a Weapons of Mass Destruction Civil Support Team.

	Assessment of Agent: Once it is established that some chemical agent has most likely been released, the next task is to establish the identity and physical properties of the chemical used in the attack. It is only once the agent has been identified that responders can properly plan further operations, such as establishing an outer perimeter, decontamination, equipment requirements, evacuation, and medical treatment. page 1 of 2

	Assessment of Agent: The agent is assessed by: a) Clinical signs and symptoms First responders can identify which chemical agent has been used by observing the symptoms of the victims and interviewing conscious victims to determine what occurred. b) Detection equipment A provisional identification can be made at the site of the release using chemical detection tickets, tubes, and paper or more sophisticated hand-held electronic detectors. Although these detection tools are not foolproof, this is likely to be the best that responders can do immediately following an attack. Samples should also be taken at the scene so that they can be sent to a laboratory for further analysis later on. page 2 of 2

	Hot Zone Triage and Treatment / Gross Decontamination: Once the chemical used in the attack has been identified, the next step is to establish safety zones. For chemical agents that do not degrade or dissipate naturally, decontamination is necessary to prevent exposing responders or re-exposing victims. The safety zones are: a) the HOT ZONE, the area directly affected by the chemical release (this can vary in size and may grow as the chemical spreads) b) the WARM ZONE, an area outside the hot zone where those who are contaminated can be brought. People and equipment are decontaminated in the warm zone so that they will not contaminate areas that remain unaffected by the chemical release. page 1 of 4

	Hot Zone Triage and Treatment / Gross Decontamination: The safety zones are: c) the COLD ZONE, an area where there is no risk of exposure or contamination where those who have been decontaminated can go. Decontamination locations (in the warm zone) are generally located upwind and uphill from the release site. Live victims (according to the severity of their medical condition) are rescued from the hot zone and brought to the warm zone for decontamination. If absolutely necessary, treatment can be administered before decontamination in the case of critical casualties, page 2 of 4

	Hot Zone Triage and Treatment / Gross Decontamination: but treatment usually takes place after decontamination, once the patient is in the cold zone. The highest priority for decontamination and treatment is given to victims with the most severe medical symptoms who can still be saved and those with clear evidence of contamination. Gross decontamination will begin with those victims having visible deposits of agent on their person, such as agent-soaked clothing or visible amounts of agent on their skin. Responders will likely remove victims' clothing and rinse off the patient with water, if available, or wipe the agent from victims' skin. page 3 of 4

	Hot Zone Triage and Treatment / Gross Decontamination: Treatment depends on the type of agent used. For instance, with nerve agent exposure, it is vital to apply antidotes (atropine and 2-PAM chloride injections) as soon as possible following exposure. For exposure to cyanide, antidotes also need to be given shortly after an attack in order to be effective. It must be remembered that any work done in the hot or warm zone will require emergency personnel to work in restrictive protective equipment. page 4 of 4

	Mitigation Begins if Release Ongoing: If the source of the chemical is continuing to release the agent (for instance a canister is still producing gas), first responders wearing protective clothing will work to prevent any further release of agent. In the event of a large chemical release, a plume can form, which can threaten the downwind area. In this case, responders may need to act quickly to evacuate the potentially affected locations. Particular attention should be paid to weather and wind conditions.

	Further Triage and Treatment / Intensive Decontamination / Casualty Collection Points: Once secure in the warm zone, victims can be further triaged and decontaminated. The more serious cases that can benefit from immediate care will be dealt with first. One of the most basic methods of decontamination is to thoroughly rinse those exposed with water. Decontamination therefore requires large volumes of water. There are also a number of solutions (such as 0.5% hypochlorite solution for skin and 5% for equipment and clothing) and powders that can be used for decontamination, depending on the chemical. Flour, baking powder, sawdust, bleach, and even soap and water can be used page 1 of 2

	Further Triage and Treatment / Intensive Decontamination / Casualty Collection Points: for decontamination if special products are not available. Once decontaminated, victims are taken to the cold zone and medical personnel out of the constraints of protective clothing can undertake treatment (see treatment description above). A central collection point will be established where victims can be taken after receiving emergency treatment and then picked up and transported to hospitals. At the same time, a temporary morgue area may be established in the warm zone for the deceased, who must still be decontaminated before they can be removed. page 2 of 2

	Long Term Decontamination of Release Site: In the case of persistent agents, long-term decontamination will occur once all casualties have been removed. Teams from federal agencies such as the Environmental Protection Agency will most likely undertake this. The contaminated area around the release site, including the soil and vegetation, will be thoroughly decontaminated using a variety of methods. If the agent is not persistent, emergency personnel will simply need to wait the required length of time until it has dissipated.

	Transport to Hospital: In addition to regular ambulance services, mass transportation and emergency medical transports will be used to transport decontaminated casualties to the hospital.

	State and Federal Advice and Assistance: Depending on the circumstances of the incident, it may be necessary to involve other state and federal agencies as soon as possible. Local agencies will contact state and federal bodies for both technical advice and direct assistance. Agencies that could be contacted include the nearest field office of the Federal Bureau of Investigation (FBI), the Federal Emergency Management Agency (FEMA), state offices of emergency services (OES), military units, and specialized medical personnel/units. For example, the incident command center might be in contact with state and federal agencies coordinating the delivery of antidotes in cases where there are insufficient supplies locally. page 1 of 2

	State and Federal Advice and Assistance: Department of Defense Weapons of Mass Destruction Civil Support Teams can arrive to assist local authorities within 4 to 12 hours. Some federal agencies, such as the FBI, may be alerted and arrive on the scene earlier in the incident. The FBI is designated as the lead federal agency in responding to a mass-casualty terrorism incident and will take over the coordination of federal response assets. It will collect evidence and can have an agent on the scene within two hours. page 2 of 2

	Hospital Treatment: Hospitals will be responsible for the long-term care of all victims. In the case of a large-scale chemical attack, hospital staff will need to put into operation their plans for a mass-casualty chemical incident, including relocating existing patients, operating in protective clothing, making space for treating numerous patients, and contact- ing other hospitals to handle overflows and to arrange the transfer of medical supplies. On arrival at the hospital, some victims may not already have been decontaminated or may require further decontamina- tion. Hospitals will therefore need to provide a triage and deconta- mination station either inside or outside the facility and ensure that there is only one point of entry and exit to the hospital so that no contaminated patients are admitted into the clean areas.